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^R  MANUAL   No.  3 


|DI( 

ithorized    by  the  Secretary  of  War 
•  the  Supervision   of  the  Surgeon-General 
\i  the   Council   of  National    Defense 


|:ary  Ophthalmic 
Surgery 

[LLEN  greenwood;  m:B. 

jlErT.-COLONEL,  MKIHCAL  CORPS,  U.  S.  A. 
ARY  LIEUT.-COLONEL,  HARVARD  SURGICAL  UNIT  WITH  THE 
Y    MEDICAL    CORPS,   BRITISH   EXPEDITIONARY  FORCE 

Chapter  on   Trachoma,  Other   Contagious 
|cTiv.\L  Diseases  and  Gas  Conjunctivitis 

G.  E.  DE  SCHWEINITZ,  M.D. 

-lEUT. -COLONEL,  MEDICAL  CORPS,  U.  S.  A. 
AND    A 

IChapter  on  Ocular  Malingering 
WALTER  R.   PARKER,  M.D. 

COLONEL,  MEDICAL   CORPS,  U.  S.    A. 

\d  edition,  thoroughly  revised 
llluatrateO 


LEA   &   FEBIGER 

LADELPHIA    AND    NEW   YORK 
1918 


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Y  PHONE 


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MEDICAL  WAR  MANUAL   No.  3 

Authorized    by  the  Secretary  of  War 

and    under  the  Supervision   of  the   Surgeon-General 

and  the  Council  of  National   Defense 


Military  Ophthalmic 
Surgery 

By  ALLEN  GREENWOOD,'  M.d.     ' 

lieut.-coloneL,  medical  corps,  u.  s.  a. 

recently  honorary  lieut.-colonel,  harvard  surgical  i'nit  with  the 

royal  army  medical  corps.  british  expeditionary  force 

Including  a  Chapter  on   Tr.\choma,  Other   Contagious 
Conjunctival  Diseases  and  Gas  Conjunctivitis 

By  G.  E.  de  SCHWEINITZ,  M.D. 

LIEUT.-COLONEL,  MEDICAL  CORPS,  U.   S.   A. 
AND    A 

Chapter  on  Ocular  Malingering 
By  WALTER  R.   PARKER,  M.D. 

COLONEL,  MEDICAL   CORPS,  U.  S.    A. 

SECOND  EDITION,  THOROUGHLY  REVISED 

TllluettateO 


LEA   &   FEBIGER 

PHILADELPHIA   AND    NEW   YORK 
1918 


(^1 


BIOLOGY 
UBRAR^f 

G 


COPYRIGHT 

LEA  &  FEBIGER 
1918 


PREFACE  TO  THE  SECOND  EDITION. 


Owing  to  the  absence  of  Lieut. -Colonel  Greenwood 
on  overseas  duty,  it  has  not  been  possible  to  secure 
the  achantage  of  his  revision  of  the  section  devoted 
to  Military  Ophthalmic  Surgery.  The  Editor  has 
added  a  few  paragraphs,  suggested  by  his  experi- 
ence abroad,  distinguished  by  being  placed  within 
brackets,  the  most  important  of  which  are:  Con- 
tusions Hypotony;  Cartilage  Prosthesis;  Implanta- 
tion after  Remote  Enucleation;  Technic  of  Extrac- 
tion of  Intra-ocular  Metallic  Foreign  Bodies  in 
British  "Eye  Centers"  in  France. 

The  chapter  on  Trachoma  has  been  revised  by 
its  author  and  an  additional  operative  procedure, 
the  one  recommended  by  the  trachoma  experts 
of  the  Public  Health  Service,  has  been  included. 

The  chapter  on  Examination  of  Malingerers  has 
also  been  re\'ised  by  its  author  and  the  tests  for 
detecting  simulated  l)ihiU'ral  blindness  have  been 
added. 

The  authors  express  their  high  appreciation  of 
iIk'  cordial  reception  which  has  been  accorded  to 
this  small  manual  and  trust  the  new  edition  may 
find  fa^'or  among  those  for  whom  it  was  written. 

LlEUT.-COLONEL   DE   SCHWEINITZ, 


i«4:^iii         (iii) 


Editor. 


PREFACE  TO  THE  FIRST  EDITION. 


This  hand-book  has  been  compiled  with  the  idea 
of  providing,  in  condensed  form,  suggestions  that 
may  be  helpful  to  medical  officers  who  have  to 
deal  with  the  special  ophthalmic  problems  which 
arise  in  the  daily  routine  of  active  army  medical 
work,  especially  in  the  dressing  stations  and 
hospitals  throughout  the  war  zone.  The  surgical 
methods  described  have  proven  their  worth  in  hos- 
pitals in  the  British  Army.  The  book  is  in  no 
sense  a  complete  treatise  on  ophthalmic  surgery. 
For  the  multitude  of  ophthalmic  operations  and 
procedures  which  are  common  to  civilian  as  well 
as  army  life  a  reference  to  the  well-recognized 
text-books  is  suggested.  The  many  operations, 
therefore,  such  as  plastics,  which  will  be  required 
for  later  army  and  civilian  reconstruction  work, 
have  not  been  included  or  described  here. 

Realizing  the  danger  of  trachoma  and  its  spread 
in  an  army  and  understanding  the  tendency  of 
recruits  to  malinger,  the  author  appreciates  to  the 
fullest  extent  the  great  advantage  of  the  chapters 
on    Trachoma    and    Malingering    so    kindly    con- 

(iv) 


PREFACE    TO    THE   FIRST   EDITION  v 

t  ril)u U'd  by  Drs.  George  E,  de  Schweinitz  and 
Walter  R.  Parker,  and  extends  his  thanks  accord- 
ingly. These  chapters  should  be  of  especial  value 
to  the  officers  conducting  cantonment  examinations. 

A.  G. 

Washington,  1917. 


CONTENTS. 

Military  Ophthalmic  Surgery     ....       7 

By  Allen  Greenwood,  M.D. 

Trachoma  and  Common  Forms  of  Conjunc- 
tivitis; Gas  Conjunctivitis    ....     61 

By  G.  E.  de  Schweinitz,  M.D. 

Examination  OF  Malingerers       .      .     .      .113 

By  Walter  R.  Parker,  M.D. 


(vi) 


MILITARY  OPHTHALMIC  SURGERY. 
By  Allen  Greenwood,  M.D., 


LIEUT.-COLONEL,    M.  C,  U.  3.  A. 


No  previous  war  has  afforded  an  opportunity  for 
the  work  of  the  ophthalmologist  such  as  the  present 
conflict  presents.  Therefore  a  chapter  on  military 
ojihthalmic  work  will,  of  necessity,  be  largely  a 
record  of  recent  personal  experiences.  Many  Eng- 
lish ophthalmologists  have  had  a  much  wider 
exi)eriencc  than  the  author,  but  during  two  seasons 
with  the  Harvard  Surgical  Unit,  British  Expedi- 
tionary Force,  General  Hospital  No.  22,  in  France 
and  consulting  in  the  surrounding  Base  Hospitals 
an  opportunity  was  afforded  for  observing  and 
carrying  out  many  varieties  of  ophthalmic  technic. 

Of  the  sick  and  wounded  soldiers  who  come 
into  Base  Hospitals,  about  10  j)or  cent,  require 
some  immediate  examination  or  treatment  of  the 
eyes  or  surrounding  structures,  or  subsequent 
examination  and  treatment.  Of  the  cases  requir- 
ing  later  examination   the   largest   percentage  are 

(7) 


8  MILITARY   OPHTHALMIC  SURGERY 

furnished  by  those  where  fundus  or  visual  field 
examinations  are  asked  for  by  the  internist  and  the 
brain  surgeon.  Many  soldiers  who  have  severe 
devastating  body  injuries  may  subsequently  show 
signs  of  an  apparently  minor  eye  injury  which  has 
been  masked  by  the  graver  illness,  but  which  later 
proves  lauch  more  serious.  It  is  important  that 
the  general  surgeon.,  as  well  as  the  ophthalmologist, 
shoald  be  alive  to  the  po'^sibility  of  such  occurrences. 
It  is  not  a  credit  to  the  ophthalmic  surgeons  to  have 
a  soldier  return  to  his  home  to  convalesce  following 
the  loss  of  an  arm  or  leg  and  have  an  iridocyclitis 
develop  in  one  eye,  as  a  result  of  an  overlooked 
intra-ocular  foreign  body,  and  then  to  lose  the 
other  eye  from  sympathetic  ophthalmitis.  It  is 
also  important  for  the  ophthalmic  surgeon  to  care- 
fully inspect  and  watch  the  good  eye  while  treating 
an  injured  one  and  it  is  equally  important  that  any 
wounded  soldier  should  have  available  for  the 
examination  and  treatment  of  his  eye  injuries  an 
experienced  ophthalmologist.  For  still  graver  and 
more  complicated  eye  conditions  there  should  be 
also  available  for  him  an  ophthalmic  surgeon  of 
even  wider  experience  as  a  consultant.  In  the 
majority  of  late  disco\'ered  cases  of  intra-ocular 
foreign  bodies  the  wound  of  entrance  has  healed 
and  often  cannot  be  found.  The  foreign  body  may 
have  passed  through  the  upper  lid  and  the  sclera  into 
the  vitreous,  leaving  no  visible  conjunctival  wound. 


CONTUSIONS  OF   THE   EYEBALL  9 

and  as  the  majority  of  men  who  enter  the  hospital 
liave  been  wounded  or  exposed  to  wounds  the 
ophthalmic  surgeon  should  always  be  on  the  look- 
out for  undiagnosed  intra-ocular  foreign  bodies. 
Any  soldier  who  complains  of  a  recent  blurring  of 
\ision  of  either  eye  should  have  a  careful  inspec- 
tion and  ophthalmoscopic  examination  under  mydri- 
asis, and  if  there  is  no  circumcorneal  injection,  the 
pupil  dilates  readily  and  the  vitreous  appears  clear, 
the  presence  of  a  foreign  body  is  unlikely  and  the 
blurred  vision  due  to  some  other  cause,  such  as  the 
amblyopia  that  is  found  in  so-called  cases  of  shell 
shock;  but  a  suffused  eye,  with  circumcorneal  injec- 
tion and  signs  of  uveal  congestion  or  beginning 
iridocyclitis,  should  be  viewed  with  grave  suspicion 
and  be  subject  to  a  careful  x-ray  examination. 
Small  fragments  of  aluminum  may  not  show  by  the 
.v-rays,  but  all  other  metallic  bits  will  unless  too 
minute.  The  author  saw  one  patient  where  the 
track  of  a  foreign  body  could  be  followed  through 
the  eye  to  its  lodgment  in  the  sclera  above  the 
macula.  It  was  half  a  disk  diameter  in  size,  looked 
like  silver,  but  on  repeated  trials  gave  no  shadow 
with  the  .v-rays.  There  was  no  reaction  and  no 
attempts  were  made  toward  its  removal. 

[It  is  important  that  every  eye  on  which  there  is 
only  a  small  patch  of  redness,  which  may  conceal 
the  entrance  of  a  minute  metallic  foreign  body, 
should  be  tested:  "put  up  to  the  magnet,"  as  the 
procedure  is  usiialK'  called.] 


10  MILITARY   OPHTHALMIC  SURGERY 

CONTUSIONS  OF  THE  EYEBALL. 

Contusions  of  the  eyeball  are  among  the  com- 
mon injuries  seen  and  may  vary  from  the  slightest 
contusion,  which  results  in  a  rapidly  disappearing 
commotio  retinae,  to  the  severe  hopeless  case  with 
a  rupture  of  all  the  tunics  of  the  eye,  causing  a 
gaping  wound  and  extrusion  of  the  globe  contents. 
Between  these  two  extremes  will  be  found  many 
grades,  including  single  or  multiple  ruptures  of  the 
retina  and  choroid,  with  or  without  vitreous  hemor- 
rhage; tears  of  the  iris  sphincter  with  hyphemia 
and  permanent  loss  of  reaction;  iridodialysis,  par- 
tial and  complete  lens  dislocations,  even  to  subcon- 
junctival luxations.  These  varying  grades  of  con- 
tusions may  be  produced  in  many  ways,  such  as 
direct  blows  on  the  anterior  portion  of  the  eye  by 
spent  or  grazing  missiles;  sudden  air  expansions  by 
nearby  explosions  or  passing  high-velocity  bullets. 
Equatorial  contusions  are  often  produced  by  some 
portion  of  the  surrounding  bones  being  driven 
against  the  eye,  or  the  vibratory  effect  of  their 
being  struck,  the  malar  bone  and  the  outer  ridge  of 
the  orbit  being  particularly  vulnerable.  Posterior 
contusions  may  be  produced  by  bullets,  shrapnel 
balls  and  pieces  of  shell  casing  entering  the  pos- 
terior part  of  the  orbit.  One  soldier  was  obser^'ed 
who  had  a  bullet  which  had  entered  behind  the 
left  ear  and  finally  penetrated  the  left  eye,  so  that 
the  point  could  be  seen  with  the  ophthalmoscope 


V 


^ 


coyrusiONS  of  the  eyeball  ii 

(Plate  I).  I'or  the  large  anterior  ruptures,  involv- 
ing all  the  tunics,  with  extrusion  of  most  of  the 
globe  contents,  enucleation  is  necessary.  For  smaller 
anterior  ruptures,  with  iris  or  ciliary  prolapse,  the 
treatment  by  conjunctival  keratojDlasty  as  described 
later  is  applicable.  Treatment  of  the  dislocated 
lenses  is  described  in  the  paragraph  devoted  to 
traumatic  cataracts.  For  other  cases  of  contusion 
\ery  little  immediate  special  treatment  is  necessary. 
Rest  and  the  application  of  compresses  wrung  out 
of  ice-water  are  extremely  useful  in  most  cases  for 
the  first  twenty-four  hours  or  longer.  One  should 
always  be  on  the  watch  in  cases  of  partial  lens 
dislocation  for  the  secondary  glaucoma  which  occa- 
sionally occurs,  and  for  this  reason  the  routine  use 
of  atropin  is  to  be  avoided.  Unless  the  outer  coat 
is  ruptured  bandaging  is  inadvisable.  For  the  after- 
treatment  of  eyes  that  show  vitreous  blood-clot, 
massage,  dionin  and  subconjunctival  injections  may 
help  in  the  clearing,  though  often  the  blood-clots 
organize  and  a  proliferating  condition  with  subse-  i 
quent  shrinking  results. 

[Contusion  Hypotony. — The  statement  that 
reduced  intra-ocular  tension  is  an  important  sign 
of  perforating  scleral  wounds,  and  especially  of 
valuable  diagnostic  import,  where,  for  example,  a 
small  penetrating  wound  of  the  sclera  is  covered 
with  tumid  and  swollen  conjunctiva,  must  not  be 
accei)tc'd   unreservedly  in  view  of  many  observa- 


2 


12  MILITARY   OPHTHALMIC  SURGERY 

tions  during  the  present  war.  In  other  words, 
reduced  intra-ocular  tension  of  the  eyeball  after 
injury  and  with  only  the  slightest  external  mani- 
festations does  not  necessarily  mean  wound  or 
rupture  of  the  globe.  The  contusion  caused  in  the 
manner  already  described  may  create  a  hypotony 
of  short  or  long  duration  and  be  associated  with 
grave  internal  lesions — vitreous  hemorrhage,  vitre- 
ous infiltrations,  rupture  of  the  choroid,  etc.  The 
lowered  tension  may  be  due  to  increased  rate  of 
excretion  of  intra-ocular  fluid  through  expanded 
channels  of  exit,  to  paresis  of  intra-ocular  nerves, 
to  rupture  of  the  pectinate  ligament  or  to  detach- 
ment of  the  pars  ciliaris  retinae.] 

WOUNDS  OF  THE  EYEBALL. 

Most  of  these  wounds  are  produced  by  flying 
fragments  of  shell  casing,  bits  of  exploding  hand 
grenades,  unburned  cordite  or  sand  and  gravel 
thrown  into  the  eyes  by  the  explosion  of  shells 
among  the  sandbags  of  the  trench  parapets.  Burns 
of  the  lids,  conjunctivae  and  cornese  from  liquid  fire 
or  nearby  explosions  are  frequent.  Bullets  and 
shrapnel  balls  cause  many  of  the  most  destructive 
injuries,  especially  the  former. 

Of  the  superficial  wounds  the  majority  consist  of 
foreign  bodies  in  the  cornea,  conjunctiva  and 
sclera,  and  these  are  usually  multiple.  Many  cases 
are  seen  in  which  the  corneae  are  peppered  by  fine 


CONTUSIONS  OF   THE  EYEBALL  13 

metallic  dust  which  mostly  remains  on  or  in  the 
cornea,  though  occasionally  some  may  be  driven 
with  sufficient  force  to  pass  into  the  iris  and  lens, 
when  they  have  to  be  treated  as  intra-ocular  for- 
eign bodies.  The  corneal  foreign  bodies  can  be 
remo\cd  by  using  a  spud  or  broad  cataract  needle. 
A  well -sharpened  gouge  is  very  useful,  or  the  point 
of  a  Beer  knife  and  much  time  and  patience  and 
a  steady  hand  are  required  for  these  procedures, 
llie  point  of  the  knife  or  gouge  can  be  carefully 
worked  beneath  the  foreign  body  and  then  by  a 
slight  lever  movement  the  particle  may  be  lifted 
out.  Care  must  be  taken  not  to  push  the  particle 
through  into  the  anterior  chamber.  Sometimes 
after  a  piece  of  steel,  deeply  embedded,  has  been 
loosened  by  the  knife  it  can  be  drawn  out  by  using 
the  magnet.  Soldiers  are  often  brought  in  who 
ha\'e  had  one  or  both  eyes  peppered  by  unburnt 
cordite,  leaving  pasty  yellowish  masses  embedded 
in  the  conjunctiva  and  cornea  and  in  many  cases 
in  the  iris  and  lens.  The  corneal  masses  may  be 
largely  remo\'ed,  always  exercising  great  care  not 
to  harm  healthy  tissue  or  penetrate  the  anterior 
chaml)er.  The  deeper  and  finer  particles  will  grad- 
ually be  thrown  off  and  then  the  healing  is  usual!}' 
prompt.  For  good-sized  pieces  embedded  in  the 
iris  an  iridectomy  with  irrigation  of  the  anterior 
chamber  is  usually  advisable  and  attempts  may  be 
made  to  pick  off  the  pieces  lying  on  the  iris  which 


14  MILITARY   OPHTHALMIC   SURGERY 

do  not  wash  out  with  the  irrigation.  This  particu- 
lar class  of  eye  cases  calls  for  a  judgment  and  skill 
only  to  be  acquired  by  actual  experience.  The 
lenticular  cases  will  be  considered  under  the  para- 
graph devoted  to  traumatic  cataracts.  For  the 
prevention  of  ulceration  following  the  remo^•al  of 
the  foreign  bodies  one  may  use  argyrol,  White's 
ointment. 

Hydrarg.  chloridi  corrosivi  ...       .      .     gr.  i  .0081 

Sodii  chloridi gr.  v  .324 

Petrolati 5v      155.52 

nosophen  ointment, 

Nosophen 3ij  8. 

Petrolati 5J  4- 

or  simple  boric  acid  flushings.  For  the  prevention 
of  pain  nothing  serves  the  purpose  better  than  i 
per  cent,  solution  of  holocain,  and  in  most  cases 
atropin  is  advisable.  Many  cases  of  simple  abra- 
sions of  the  cornese  are  seen  and  most  of  these 
present  some  ulceration.  Fortunately  the  ser- 
piginous type  of  ulcer  is  almost  never  seen,  but 
hypopyon  keratitis  is  common.  These  abrasions 
yield  readily  to  the  holocain,  argyrol  and  atropin 
medication.  If  the  abrasion  is  fairly  deep  and  a 
large  ulcerated  area  left  this  may  be  made  to  heal 
much  more  quickly  by  covering  it  with  a  conjunc- 
tival flap.  For  lid  burns,  ice-water  compresses  and 
boric  ointment  are  best,  and  for  conjunctival  and 


PENETRATING    AND   PERFORATING    WOUNDS   OF   EYE    15 

corneal  burns  the  atropin  and  cocain  alkaloid 
solution  in  castor  oil.  For  finding  small  ulcers  and 
abrasions  and  outlining  them  and  to  outline  small 
corneal  foreign  bodies  a  solution  of  fluorescein  is 
of  great  help  and  should  always  be  at  hand.  The 
following  is  the  formula  for  the  solution: 

Fluorescein gr.  viij      .123 

Liq.  potassae 5ss  2. 

Aquae  dest 5j         20.. '^i 

PENETRATING  AND  PERFORATING  WOUNDS  OF  THE  EYE. 

Such  wounds  of  the  eye  will  test  the  skill  of  the 
ophthalmologist  more  than  any  other  line  of  work 
done  in  the  Army  Hospital,  and  it  is  here  that  the 
greatest  good  can  be  accomplished  in  the  preven- 
tion of  blindness.  The  most  difficult  problems  are 
those  w^here  a  penetrating  foreign  body  remains 
in  the  eye  instead  of  perforating  and  passing  into 
the  orbit  or  beyond.  The  method  of  treating  these 
penetrating  wounds  with  the  presence  in  the  globe 
of  one  or  more  foreign  particles  depends  largely  on 
the  size  and  shape  of  the  pieces  and  whether  or 
not  magnetic.  When  the  penetrating  foreign  body 
is  quite  large  the  eye  is  usually  so  badly  lacerated 
and  so  much  vitreous  lost  that  any  attempt  to 
remove  the  large  and  jagged  piece  would  result  in 
still  more  laceration  and  loss,  so  that  such  eyes 
should  be  enucleated,  or  if  in  a  condition  of  well- 
established  panophthalmitis,  eviscerated.     On  enu- 


16  MILITARY   OPHTHALMIC  SURGERY 

cleating  these  eyes  it  is  usually  found  that  the 
vitreous  has  been  replaced  by  a  large  clot  of  blood 
and  the  extreme  softness  of  such  eyes  with  an 
absolute  loss  of  vision  constitutes  an  indication  for 
early  enucleation. 

Enucleation  and  Metallic  or  Glass  Pros- 
thesis.— This  brings  up  the  whole  question  of  the 
proper  methods  of  enucleation,  and  the  author 
wishes  to  urge  at  this  time  that  soldiers  so  injured 
should  have  an  operation  that  will  provide  for  them 
a  socket  for  the  wearing  of  an  artificial  eye  that  will 
give  the  best  cosmetic  results.  A  man  who  has 
given  his  eye  for  his  country  deserves  certainly  no 
less  than  this.  If  it  is  thought  desirable  to  do  a 
simple  enucleation  the  least  that  the  ophthalmic 
surgeon  can  do  is  to  sew  the  four  recti  muscles 
together;  but,  better  still,  some  form  of  implantation 
operation  is  a  much  more  advisable  procedure,  and 
every  soldier  should  have  the  benefit  of  such  when 
possible.  In  the  ordinary  Base  Hospital,  where 
much  infection  is  always  present,  an  additional 
wound  of  the  body  to  obtain  fat  for  implantation 
in  Tenon's  capsule  is  contra-indicated.  During  the 
summer  of  1916  the  author  had  the  opportunity 
of  implanting  over  thirty  glass  globes  where  it  was 
necessary  to  do  an  ordinary  enucleation.  A  glass 
ball  of  at  least  18  to  20  mm.  diameter  was  always 
used,  for  the  use  of  this  large  size  rendered  the 
possibility  of  extrusion  of  the  globe  less  likely,  and 


PEXi:rRATI\G   A.Wn   perforating    wounds   of   eve     17 

this  assertion  was  borne  out  by  the  fact  that  of 
those  mentioned  above  as  having  been  implanted 
all  remained  in.  Gold  balls  are,  of  course,  expen- 
sive, so  that  the  implantation  of  the  glass  ball  is 
surely  the  operation  of  election,  and  if  carefully 
inserted  with  proper  suturing  of  Tenon's  capsule 
over  the  ball  always  before  the  suturing  together 
of  the  muscles  the  likelihood  of  extrusion  is  largely 
eliminated.  For  the  suturing  of  Tenon's  capsule 
and  the  muscles  as  well  as  the  conjunctiva,  the 
author  uses  fairly  fine  twisted  silk  and  the  smallest 
full-curved  needles.  The  silk  thus  buried  beneath 
the  conjunctiva  is  almost  never  seen  again.  In  a 
pre\ious  article^  the  author  has  drawn  attention  to 
the  great  advantage  of  placing  the  sutures  verti- 
cally in  the  conjunctiva  in  order  to  retain  as  long 
a  palpable  fissure  as  possible  and  thus  avoid  the 
dragging  of  the  external  canthus  toward  the  center 
which  results  from  a  purse-string  suture  of  the 
conjuncti\a.  By  the  use  of  the  above-mentioned 
size  of  globes,  following  the  method  outlined,  one 
is  able  to  pre\'ent  permanently  any  sinking  in  of  the 
upper  lid  such  as  will  follow  any  other  method. 
With  a  prosthesis  in  place  and  the  lids  closed  there 
should  be  no  difference  in  the  appearance  and  level 
of  the  two  up{)er  lids.     Any  soldier  who  obtains 

'  Enucleation  wilh  Implantation  of  Hollow  Gold  or  Glass  Ball;  A 
Plea  for  its  More  General  Adoption,  Archives  of  Ophthalmology,  1914, 
vol.  xliii. 


18  MILITARY   OPHTHALMIC  SURGERY 

less  than  this  after  enucleation  is  not  receiving  the 
best  results  possible. 

[Cartilage  Prosthesis. — The  implantation  of 
glass  or  gold  balls  in  the  manner  described  in  the 
previous  paragraph  does  not  meet  the  favor  it  has 
received  from  American  surgeons  among  English 
and  French  ophthalmic  surgeons.  Mayard,  for 
example,  places  himself  on  record  that  plastic 
surgeons  are  a  unit  as  to  the  superiority  of  natural 
tissues  in  contrast  to  metallic  or  glass  prosthesis. 
He  is  satisfied  that  transferred  cartilage  establishes 
fresh  communications  with  the  bloodvessels  in  its 
vicinity,  and  becomes  fixed  to  the  capsule  in  recent 
enucleations.  Even  if  the  cartilage  after  implan- 
tation is  transformed  into  a  species  of  fibrous  tissue, 
it  is  believed  by  many  surgeons  that  the  cosmetic 
result  is  not  disturbed.  For  the  purpose  of  making 
cartilage  implantation,  generally  the  eighth  rib  is 
selected  and  the  globe  of  cartilage  removed  with  a 
trephine  of  such  size  as  is  suited  to  the  conditions. 
The  cartilage  having  been  introduced  within  Tenon's 
capsule  it  is  sutured  to  the  inside  or,  if  possible,  the 
four  straight  muscles  are  attached  by  means  of 
sutures  to  this  cartilage  sphere;  the  rest  of  the  oper- 
ation proceeds  as  has  already  been  described.  It  has 
been  stated  that  such  grafts  may  be  used  even  in 
the  presence  of  septic  eyes  or  septic  sockets.  Such 
use  of  cartilage  implantation,  that  is,  in  the  presence 
of  septic  sockets,  the  editor  did  not  witness  during 


PEXErRATI^'G   AXD   PERFORATING    WOUNDS   OF  EYE    19 

his  senicein  France,  and  therefore  cannot  personally 
state  whether  the  procedure  would  be  wise  or  not. 

In  place  of  human  cartilage  it  is  the  practice  of 
some  surgeons,  notably  INIagitot,  to  use  formalized 
cartilage  taken  from  a  calf-  or  lamb-rib.  This  is 
l^laced  in  formol,  lo  per  cent.,  for  three  days,  and 
afterward  freed  from  the  formol  by  successive 
washings  in  sterile  water.  It  is  most  important 
that  there  shall  be  a  thorough  remo\'al  of  all  traces 
of  the  formol  before  the  cartilage  is  implanted, 
w  hich  can  be  shaped  to  any  size  that  is  rec^uired  for 
the  purpose  of  the  implantation. 

Terrien  recommends  a  graft  of  cartilage,  generally 
rib  cartilage,  1.5  cm.  in  length,  to  which  the  tendons 
of  the  rectus  muscles  are  sutured.  In  default  of 
the  graft  prosthesis  he  greatly  improved  the  appear- 
ances by  using  artificial  stumps  of  hard  ebonite 
shell  in  an  envelope  of  soft  India  rubber,  which  was 
molded  to  the  bottom  of  the  conjunctival  sac,  or 
molds  of  wax  were  placed  behind  the  artificial  eye. 

It  is  perfectly  possible  to  improve  badly  formed 
sockets  after  primary  enucleation  by  the  implanta- 
tion of  a  glass  or  gold  ball  into  the  orbit,  an  opera- 
tion to  which  Webster  Fox  gave  the  name  "implan- 
tation after  remote  enucleation  of  an  eyeball." 
Should  this  operation  be  undertaken,  for  example, 
on  the  right  orbit,  after  the  eyelids  are  separated 
by  means  of  a  speculum,  the  conjunctiva  is  grasped 
up  and  in  above  the  inner  canthus  and  the  tissues 


20  MILITARY   OPHTHALMIC   SURGERY 

are  well  pulled  out.  Next,  a  Beer  knife  or  curved 
keratome  is  passed  through  the  tissues  somewhat 
obliquely  and  well  down  into  the  orbit  and  an 
opening  made  large  enough  for  the  insertion  of  the 
globe  behind  the  tissues.  This  opening  may  be 
enlarged  with  curved  scissors  to  the  desired  size. 
When  ready  a  gold  ball  is  inserted  through  the 
opening,  which  is  closed  with  stitches,  and  over 
which  a  shell  is  placed,  modelled  after  an  artificial 
eye.  The  eyelids  are  then  closed  over  this  shell, 
which  is  left  in  place  for  twenty-four  hours.  The 
stitches  are  taken  out  on  the  third  day.  If  the 
operation  is  to  be  performed  on  the  left  orbit  the 
incision  is  made  up  and  out,  above  the  external 
rectus  muscle,  and  the  dissection  carried  out  as 
previously  described. 

In  place  of  the  implantation  of  a  glass  or  gold 
ball  a  cartilage  sphere  or  graft  may  be  used  and 
stitched  into  place,  with  the  result  of  much  improv- 
ing the  appearances  of  the  artificial  eye,  and  pre- 
venting, or  rather  obviating,  the  unsightly  or  sunken 
appearance  which  only  too  often  follows  badly  per- 
formed enucleations.] 

In  the  torn  eyes  that  present  a  panophthalmitis, 
with  or  without  an  orbital  cellulitis,  the  ordinary 
enucleation  should  have  substituted  for  it  an  evis- 
ceration. The  simplest  method  of  doing  this  is  to 
make  a  circular  cut  just  back  of  the  ciliary  body 
and  in  front  of  the  recti  muscle  attachments.    The 


PENETRATING  AND   PERFORATING    WOUNDS   OF   EVE    21 

contents  of  the  globe  can  then  be  scrubbed  out 
with  pledgets  of  gauze  until  nothing  is  left  but  the 
white  sclera,  which  may  then  be  cauterized  lightly 
with  crude  carbolic  acid.  The  dusting  in  of  iodo- 
form powder  helps  to  lessen  infection  and  subse- 
quent purulent  discharge.  The  pocket  may  then 
be  filled  with  White's  ointment.  It  is  necessary 
to  suture  the  conjunctiva  or  sclera,  for  the  healing 
takes  place  \-ery  rapidly  with  the  formation  of  the 
customary  quadrilateral  shaped  stump  w^hich  forms 
a  fair  substitute  for  the  larger  stump  resulting 
from  the  glass-ball  implantation.  This  is  a  very 
simple  method  of  evisceration,  and  the  after-results 
from  the  performance  of  a  great  many  were  in\a- 
riably  good.  The  principal  ad\antage  of  this  pro- 
cedure lies  in  its  not  opening  the  optic  nerve  sheath 
and  not  disturbing  the  muscle  attachments.  For 
a  torn  and  badly  infected  eye  w^hich  often  has 
associated  an  orbital  cellulitis  the  above  method 
commends  itself  by  its  simplicity,  ease  of  execu- 
tion and  excellent  results.  In  fact,  healing  after 
this  method  takes  little  longer  than  that  after  a 
simple  enucleation  and  without  special  discomfort 
to  the  patient. 

[Colonel  Lister,  of  the  B.  E.  F.,  has  advocated 
and  practised  the  enucleation  of  a  septic  eye  with 
this  modification,  namely,  that  a  fringe  of  sclera, 
about  lo  mm.  in  width,  is  allowed  to  remain  and 
surround  the  optic  nerve  entrance,  avoiding,  there- 


22  MILITARY   OPHTHALMIC  SURGERV 

fore,  opening  of  the  optic  nerve  sheath  and   the 
danger  of  conveying  infection  through  this  route.] 

For  the  very  large  number  of  penetrating  wounds 
showing  by  direct  inspection,  or  the  x-rays,  the 
presence  of  one  or  more  foreign  bodies  in  the  globe, 
the  question  of  the  method  to  be  adopted  for  the 
early  remo\'al  of  the  foreign  particles  must  be 
considered.  About  two-fifths  of  these  intra-ocular 
foreign  bodies  are  magnetic  and,  if  such  be  the 
case,  removal  of  these  by  some  form  of  magnet 
is  usually  the  desirable  method.  Most  of  these 
magnetic  particles  lie  in  the  vitreous  chamber  and 
some  operators  will  prefer  to  attempt  the  removal 
of  these  by  what  is  called  the  anterior  and  some 
by  the  posterior  method,  through  a  scleral  incision, 
while  some  may  remove  them  by  way  of  the 
original  wound.  The  choice  of  these  three  routes- 
will  depend  largely  on  the  size,  shape  and  location 
of  the  foreign  body. 

If  one  is  to  use  the  anterior  route,  which  is  only 
applicable  to  fragments  of  small  size,  a  giant  mag- 
net, or  what  the  author  calls  "the  arm  magnet,"  of 
nearly  equivalent  strength,  is  necessary  to  give 
sufficient  power  to  draw  the  foreign  body  carefully 
from  the  vitreous,  through  the  zonule,  and  thence 
around  the  lens  into  the  anterior  chamber.  When 
the  foreign  body  has  thus  been  drawn  into  the 
anterior  chamber  it  may  be  removed  through  a 
corneal  opening  by  further  application  of  the  large 


PKMETRATIXG  A.XD    FI^RFORATI XG    WOUNDS   OF    EYE    23 

mai2:nct,  or  the  hand  magnet  may  be  substituted  for 
the  large  magnet  in  order  to  complete  the  operation. 
In  order  to  start  the  foreign  body  on  its  passage 
through  the  vitreous  a  repeated  turning  on  and  off 
of  the  magnet  current  may  coax  the  particle  for- 
ward, but  the  moment  a  bulging  of  the  iris  indicates 


Fig.  I. — Arm  magnet. 

its  presence  in  the  posterior  aqueous  chamber  the 
current  must  be  turned  off  and  the  direction  of  the 
e\e  changed  so  that  the  pull  of  the  magnet  when 
the  current  is  turned  on  may  be  parallel  to  the 
surface  of  the  lens. 

I'or  larger  foreign  bodies  in  the  \itreous,  and  for 
such  operators  as  prefer  it  for  the  smaller  also,  the 
posterior  route  may  be  chosen,  and  for  this  class  a 
very  careful  .v-ray  localization  is  especially  essen- 
tial.    In  operating  a  conjunctival  flap  is  laid  back 


24  MILITARY   OPHTHALMIC   SURGERY 

from  over  the  selected  point  in  the  sclera,  then  a 
puncture  is  made  in  the  latter  and  the  rounded  tip 
of  the  hand  magnet  applied  to  this  opening,  or  the 
pointed  tip  may  be  passed  into  the  vitreous  to  the 


Fig.  2 


vicinity  of  the  foreign  body,  the  current  applied 
and  the  particle  withdrawn.  The  incision  in  the 
sclera  should  always  be  made  meridionally  to  avoid, 
so  far  as  possible,  cutting  vessels,  and  may  be 
held  open  by  one  of  the  little  non-magnetic  scleral 


PEXETRATIXG  AND   PERFORATING    WOUNDS   OF   EYE    25 

retractors  de\'ised  for  this  purpose.  When  the  tip 
of  the  hand  magnet  is  applied  to  the  opening  in 
the  sclera  the  foreign  body  may  be  slow  in  coming 
forward  and  patience  and  persistence  in  the  appH- 
cation  of  the  magnet  may  be  rewarded  by  seeing 


Fig.  3. — Illustrating  pull  from  below. 


the  foreign  IhhW  appear.  There  will  also  be  a  cer- 
tain number  of  cases  in  which  the  foreign  body  and 
the  wound  of  entrance  are  of  considerable  size  and 
the  latter  open.  Here  it  may  be  most  advisable  to 
draw  the  foreign  body  out  through  its  wound  of 


26 


MILITARY   OPHTHALMIC  SURGERY 


entrance,  especially  in  cases  in  which  the  lens  has 
already  been  damaged.     When  using  the  magnet 


Fig.  4. — Illustrating  pull  from  above. 


in  this  way  care  must  be  taken  to  turn  the  current 
on  and  approach  the  eye  to  the  magnet  slowly,  so 
as  to  avoid  too  sudden  a  jump  of  the  foreign  body. 


PENETRATIXG   A XI)    PRRFORATING    WOUNDS   OF   EYE    27 

One  would  not  like  to  see  the  whole  of  a  patient's 
iris  on  the  magnet  tip.  As  complete  a  dilatation 
of  the  pupil  as  is  possible  is  advisable  before  any 
magnet  operation.  The  postoperative  treatment 
and  bandaging  is  the  same  as  after  any  intra- 
ocular operation.  The  author's  therapeutic  prefer- 
ence being  atropin,  argyrol,  iodoform  and  White's 
ointment,  as  indicated.  The  most  fa\-orable  cases 
are  those  in  which  the  magnetic  foreign  body  lies 
anterior  to  the  vitreous,  either  in  the  anterior  cham- 
ber, iris  or  lens.  Those  in  the  anterior  chamber 
can  be  readily  removed  through  a  small  corneal 
incision  by  the  use  of  the  hand  magnet.  If  it  is 
entangled  in  the  iris  an  effort  should  be  made  to 
disentangle  it  by  careful  use  of  the  hand  magnet 
or  forceps,  and  if  this  is  unsuccessful  an  iridectomy 
should  be  done  and  the  foreign  body  brought  out 
with  its  surrounding  iris.  If  it  is  embedded  in  the 
anterior  portion  of  the  lens  it  may  be  possible  to 
draw  it  out  with  the  magnet  into  the  anterior 
chanibcT.  from  whirh  it  can  l)c  remoxed.  If  it  is 
deeply  embedded  it  is  advisable  to  wait  until  the 
lens  becomes  opaque,  when  both  can  be  removed 
at  the  same  time.  A  large  particle  anterior  to  the 
\  itreous  is  more  likely  to  be  followed  by  permanent 
good  results  than  a  smaller  posterior  one, 

[The    technic    almost    universally   employed    by 
British  ophthalmic  surgeons  in  the  B.  E.  K.  for  the 


28  MILITARY  OPHTHALMIC  SURGERY 

extraction  of  intra-ocular  foreign  bodies  includes 
the  use  of  a  giant  magnet,  for  example,  of  the 
Haab  type,  or  one  of  equal  drawing  power,  and  a 
small  magnet  for  the  removal  of  the  body  after  it 
has  been  drawn  into  the  anterior  chamber.  As 
Whiting  and  Goulden  record  the  general  principles 
of  the  method  adopted,  they  are  these:  The  wound 
of  entrance  is  disregarded  from  the  point  of  view  of 
extraction  unless  there  is  a  large,  unhealed  wound 
in  the  cornea  or  sclera,  which  would  be  strongly 
suggestive  of  the  presence  of  a  large  foreign  body 
in  the  vitreous,  which  it  would  be  hazardous  to 
remove  by  any  other  path.  Almost  universally 
the  foreign  body  is  drawn  forward  through  the 
suspensory  ligament  of  the  lens  into  the  posterior 
chamber  and  next  through  the  pupil  into  the  ante- 
rior chamber.  From  the  latter  chamber,  through  a 
suitable  corneal  incision,  the  foreign  body  is  removed 
by  means  of  a  small  magnet.  Referring  to  the 
x-rays  and  localization  of  the  foreign  bodies,  so 
universally  practised  in  our  country,  these  authors 
state  that  its  assistance  is  by  no  means  essential 
to  successful  treatment,  and  if  localization  is  likely 
to  involve  several  hours'  delay  it  should  be  omitted. 
The  editor  noted  how  much  attention  was  paid  to 
pain  as  a  sign  of  the  presence  or  not  of  the  foreign 
body  while  watching  the  work  in  British  hospitals 
in   France,   some  magnets  being  supplied   with   a 


PENETRATING  AND   PERFORATING   WOUNDS  OF  EYE    29 

special  extension  point  for  exploring  the  surface  of 
the  sclera  in  order  to  detect  the  spot  of  pain. 

The  foreign  body  having  been  drawn  into  the 
anterior  chamber,  if  the  eye  is  red  and  tender  it  is 
usually  recommended  that  the  final  stage  of  the 
operation  shall  be  done  under  the  influence  of 
general  anesthesia.  The  corneal  incision  is  made 
above,  about  3  mm.  below  the  limbus,  the  point  of 
the  knife  being  directed  straight  toward  the  foreign 
body  and  the  incision  completed  without  any  lat- 
eral movement.  So  successfully  is  this  done  that 
very  little  aqueous  is  lost.  The  extension  point  of 
llic  magnet  is  next  directed  outside  of  the  cornea 
immediately  over  the  foreign  body  and  the  foreign 
body  is  gradually  coaxed  along  the  posterior  surface 
of  the  cornea  into  the  corneal  incision,  through 
which  it  is  withdrawn.  This  method,  briefly  summa- 
rized, meets  with  the  approval  of  Colonel  Lister 
and  is  the  outcome  of  a  very  great  experience;  but 
until  the  end-result  of  these  magnet  extractions  are 
carefully  tabulated  it  will  be  impossible  to  state 
with  accuracy  how  they  compare  with  those  which 
follow  careful  localization  and  removal  of  the  body 
by  the  scleral  route.  After  the  removal  of  foreign 
l)odies  a  treatment  with  atropin  ointment  and  iced 
compresses  is  advisable.] 

In  cases  that  present  themselves  with  a  posterior 
intra-ocular   foreign    body   which    is   non-magnetic 


30  MILITARY  OPHTHALMIC  SURGERY 

there  is  usually  very  little  that  can  be  done.  Occa- 
sionally one  will  see  a  case  in  which  the  vitreous  is 
still  clear  and  the  particle  can  be  easily  seen  with 
the  ophthalmoscope.  \Mth  a  properly  placed 
scleral  cut  the  operator  may  with  the  electric 
ophthalmoscope  see  to  guide  a  special  pair  of  foreign 
body  forceps  within  the  eye,  and  in  this  way  be 
able  to  seize  and  withdraw  the  particle.  Occasion- 
ally, also,  the  x-rays  may  show  the  foreign  body, 
by  very  careful  localization,  as  lying  in  or  on  the 
sclera,  and  if  so  it  may  be  possible  to  cut  down 
directly  onto  and  remove  it.  In  the  majority  of 
these  cases,  however,  enucleation  becomes  neces- 
sary, and  in  one  eye  removed  by  the  author  for 
multiple  intra-ocular  foreign  bodies  five  were  found 
in  the  vitreous,  of  which  only  one  was  magnetic. 
In  some  cases,  particularly  when  a  foreign  body 
like  aluminum  is  embedded  and  there  is  no  reac- 
tion, it  is  much  better  surgery  to  leave  the  eye 
alone.  It  is  a  well-known  fact  that  frequently  an 
eye  tolerates  an  encysted  or  embedded  foreign 
body  indefinitely,  and  therefore  before  removing 
such  eyes  the  surgeon  should  give  nature  all  the 
opportunity  consistent  with  safety  and  comfort. 
The  operator  must  never  consider  that  having 
removed  a  foreign  body  from  the  eye  his  work  is 
done,  for  it  has  in  reality  only  begun.  He  is  still 
confronted    by  the  danger  of   severe   iridocyclitis, 


I'EXETRAriXG  AND   PERFORATING    WOUNDS   OF  EYE    31 

vitreous  disturbances  or  retinal  separation.  For 
the  two  latter  conditions  very  little  can  be  done, 
but  for  the  former  much  may  be  accomplished. 
The  moment  an  iridocyclitis  appears  likely  the 
atropin  used  should  be  increased  in  strength  and 
instilled  more  frequently.  The  effect  of  atropin 
may  be  made  more  potent  by  the  use  of  5  to  10 
per  cent,  solution  of  dionin,  and  this  result  can 
also  be  accomplished  l)y  the  frequent  use  of  hot 
fomentations. 

Whenever  available  leeches  should  be  apj^lied 
to  the  temple,  and  the  ophthalmic  surgeon  should 
ncxer  forget  that  the  eyes  he  is  treating  are  a  i)ari 
of  the  body  and  their  welfare  is  strongly  infhi- 
ciiced  by  the  general  physical  conditions.  Soldiers 
who  have  been  forced  from  their  active  life  to 
C()mi)lete  rest  are  likely  to  become  constipated, 
and  this  should  be  carefully  looked  out  for.  In 
the  beginning  of  the  iridocyclitis  the  author  has 
l)laced  great  reliance  on  the  use  of  calomel  in  two- 
or  three-grain  doses,  followed  by  a  saline.  Inunc- 
tions of  mercury  ha\e  seemed  to  be  of  ser\ace  in 
combating  this  condition,  and  for  pain  the  use  of 
fairly  large  doses  of  aspirin  or  salicylate  of  sodium. 
If  in  spite  of  treatment  the  iridocyclitis  persists 
and  the  vision  is  lost  it  is  necessary  that  the  eye 
shuld  be  enucleated  to  prevent  the  possibility  of 
sympathetic  inilammation  in   the  sound   eye. 


>i 


32  MILITARY   OPHTHALMIC  SURGERY 

Conjunctival  Keratoplasty. — When  the  re 
•moved  foreign  body  is  of  considerable  size  it  ofter 
becomes  necessary  to  adopt  some  method  of  seal 
ing  the  wound  to  minimize  the  danger  of  infection 
and  such  cases  come  under  the  same  category  as  the 
penetrating  wounds  of  the  anterior  portion  of  the 
eye,  which  occur  in  considerable  numbers,  without 
foreign-body  inclusion.  These  wounds  occur  of  all 
sizes  and  in  all  locations,  from  the  small  perfora- 
tion near  the  limbus,  with  its  protruding  knuckle  of 
iris,  to  the  one  that  splits  the  cornea  from  limbus 
to  limbus  with  iris  prolapse  at  each  end  and  a 
traumatic  cataract  presenting  in  the  center.  These 
wounds  are  mostly  made  as  a  result  of  a  piece  of 
shell  casing  striking  some  part  of  the  bony  ridge, 
which  stops  it,  but  not  before  some  edge  or  corner 
of  the  flying  missile  has  cut  the  eye;  or  a  flying 
piece  may  pass  across  the  front  of  the  face,  cutting 
lids  and  eyeball,  to  embed  itself  finally  in  the  base  of 
the  nose  or  even  in  the  other  eye,  making  it  impera- 
tive that  everything  possible  be  done  to  save  the  cut 
globe.  Many  cases  are  seen  in  which  one  eye  has 
been  torn  out  or  into  shreds  and  the  other  eye  cut 
by  the  same  missile.  It  is  for  such  cases  that  the 
greatest  skill  of  the  ophthalmic  surgeon  is  enlisted, 
and  the  author  has  come  to  have  the  greatest  con- 
fidence in  a  well-performed  conjunctival  kerato- 
plasty as  giving  by  far  the  best  results.    It  is  advis- 


PENETRATING  AND   PERFORATING    WOUNDS   OF   EYE    33 

able  to  make  the  conjunctival  flap  and  have  the 
Biitures  inserted  before  clearing  up  the  wound  or 
cutting  off  the  iris  prolapse,  thus  lessening  the  risk 
3f  vitreous  loss.  In  removing  the  prolapsed  iris 
it  is  always  best  to  grasp  the  protruding  bit  and 
tease  it  out  before  cutting,  so  as  to  make  the 
resulting  coloboma  larger  than  the  wound  and  thus 
prevent  adhesion  to  the  edges.  Where  the  lens  is 
injured,  so  much  as  possible  of  the  swollen  sub- 
stance should  be  removed  by  suction,  irrigation,  or 
both.  When  the  wound  is  peripheral  it  is  sufficient 
to  cut  the  conjunctiva  from  the  limbus  along  half 
the  circumference  of  the  cornea,  with  the  center  of 
the  conjunctival  cut  opposite  the  corneal  or  limbus 
^vound.  After  undermining  the  conjunctiva  it  will 
be  found  possible  to  draw  it  nearly  to  the  middle  of 
the  cornea.  The  subconjuncti\al  tissue,  with  its 
rich  blood  supply  and  abundant  adhesi\'e  exudate, 
^vlll  seal  the  wound  quickly  and  allow  the  anterior 
rhamber  to  fill  and  atropin  exert  its  influence.  For 
:omeal  wounds  more  centrally  placed  or  for  wounds 
extending  across  the  cornea  a  second  curved  cut  in 
:he  conjunctiva,  about  7  or  8  mm.  from  the  circum- 
:orneal  one,  is  required  so  as  to  fashion  a  bridge  of 
:onjunctival  tissue,  which,  by  a  suture  above  and 
Delow,  can  be  drawn  across  the  center  of  the  cornea. 
In  three  or  four  days  the  bridge  can  be  sutured 
3ack  onto  its  original  position,  lea\ing  enough 
3 


34  MILITARY   OPHTHALMIC  SURGERY 

subconjunctival  tissue  In  the  wound  to  seal  It  per- 
manently and  prevent  staphyloma.     By  the  above 


Fig.  5. — By  passing  the  suture  through  a  fold  in  flap  and  then  through 
a  fold  above  a  firmer  hold  can  be  obtained  and  the  anchoring  hold 
should  include  episcleral  tissue.      (After  Kuhnt.) 


Fig.  6. — Flap  in  place.     (After  Kuhnt.) 

method  It  Is  possible  to  save  many  eyes  that  appear 
to  be  irreparably  injured  and  frequently  to  save  a 


PENETRATIXG  AND   PERFORATING   WOUNDS    OF  EYE    35 

useful    amount   of   vision;   and  the  author   would 
make  a  plea  at  this  time  that  some  such  attempt 


Fig.  7. — Bridge.     (After  Kuhnt  ) 


s^L^^% 


Fig.  8. — Bridge  in  place.     (After  Kuhnt.) 


be  made  to  save  these  apparently  hopeless  eyes, 
even  if  the  cut  passes  through  the  ciliary  body,  for 


36  MILITARY   OPHTHALMIC   SURGERY 

if  good  healing  takes  place  under  the  conjunctival 
flap,  without  any  iridocyclitis  resulting,  the  danger 
of  sympathetic  ophthalmitis  is  practically  elimi- 
nated. If,  after  such  an  attempt  at  conservative 
surgery,  there  does  appear  infection  and  iridocyclitis, 
then  the  eye  can  be  removed,  with  only  a  few  days 
lost,  and  long  before  the  danger  of  sympathetic 
ophthalmitis.  The  author  saw  no  patients  with 
this  justly  dreaded  complication  during  his  service 
and  in  no  case  did  severe  iridocyclitis  follow  a  well- 
executed  conjunctival  keratoplasty,  performed  on 
eyes  showing  no  signs  of  infection  at  the  time  of 
operation.  Two  things  to  be  remembered  are  first, 
the  advisability  of  getting  flaps  ready  and  the 
sutures  in  place  before  cutting  off  the  prolapse,  and 
thus  possibly  exposing  the  vitreous  and  causing 
loss  of  the  latter  by  the  manipulations  and  second, 
making  sure  that  the  entire  wound  is  covered 
by  the  flap  of  conjunctiva.  For  cases  where  the 
wound  extends  a  long  way  into  the  sclera,  suturing 
of  this  may  be  necessary,  followed  by  modified 
flaps  to  conform  to  the  condition.  Here  a  double 
flap  may  be  crossed  over  the  wound.  Even  in 
cases  where  there  is  a  large  prolapse  of  iris  or  ciliary 
body  that  has  been  left  several  days  and  is  very 
adherent  the  above  method  is  still  applicable  and 
far  better  than  using  the  cautery  which  the  author 
never  approves  of.  Touching  the  edges  of  the 
scleral    and    conjunctival    cuts    with    tincture    of 


TRAUMATIC   CATARACTS,  37 

iodin  has  been  advocated  and  is  a  very  useful 
procedure,  and  for  the  same  purpose  the  author 
rubs  in  hnel\-  powdered  iodoform. 

TRAUMATIC    CATARACTS. 

The  treatment  of  traumatic  cataracts,  seen  so  fre- 
quentl}-,  forms  an  important  part  of  the  work,  and 
cases  may  be  divided,  for  convenience  of  discus- 
sion, into  those  due  to  concussion  and  to  those  more 
frequently  seen  due  to  a  perforating  wound.  The 
hitter  may  occur  with,  or  without,  the  presence  of 
an  intra-ocular  foreign  body  and  after  the  rcmo\al 
of  tlie  foreign  body  these  cases  may  all  be  consid- 
ered under  the  second  of  the  above-mentioned 
di\isions.  Several  factors  should  guide  one  in  the 
treatment  of  cataracts  due  to  non-perforating  inju- 
ries. One  of  the  principal  guides  being  the  tension 
of  the  eye,  for  if  this  be  low  an  attempt  to  remove 
the  opaque  lens  is  inadvisable.  If,  however,  the 
tension  is  increased,  showing  a  glaucoma  secondary 
to  the  swelling  of  the  lens,  operative  interference 
is  a(l\isable  rather  than  depending  on  myotics, 
unless  the  latter  very  speedily  relieve  the  tension. 
The  danger  of  iritic  adhesions  in  such  cases  would 
ordinarily  make  one  doubtful  about  using  myotics, 
so  that  it  has  been  the  custom  of  the  author  to 
remove  as  much  as  possible  of  the  swollen  lens 
substance,  leaving  the  remainder  for  future  absorp- 
tion under  the  use  of  atropin  and   dionin.     Where 


38  MILITARY   OPHTHALMIC  SURGERY 

there  is  no  pus  tension  and  the  opacity  is  not  com- 
plete, it  would  be  advisable  to  leave  the  lens  alone 
unless  the  other  eye  has  previously  been  lost;  in 
which  case  operative  interference  may  be  demanded 
for  the  mental  effect  upon  the  patient  produced 
by  the  restoration  of  vision.  For  these  cases  the 
ordinary  combined  extraction  is  advised  without 
any  extensive  attempts  to  remove  all  of  the  cortical 
material,  for  these  patients  are  mostly  young  and 
experience  has  shown  that  absorption  of  such 
remaining  lens  substance  proceeds  very  rapidly.  A 
dislocated  lens  should  be  removed  if  possible.  When 
located  in  the  anterior  chamber  the  pupil  should 
be  contracted  with  eserine  or  pilocarpine  prior  to 
attempts  at  removal  and  at  the  time  of  removal  a 
needle  may  be  passed  behind  the  lens  to  prevent 
its  being  pushed  into  the  vitreous  chamber.  When 
the  lens  is  located  in  the  vitreous  the  ordinary 
cataract  incision,  preferably  with  a  conjunctival 
flap  and  an  iridectomy,  may  permit  the  operator 
to  lift  out  the  lens  by  using  the  vectis,  with  only  a 
slight  loss  of  vitreous.  Where  there  is  only  a  par- 
tial dislocation  it  would  be  better  surgery  to  let 
the  lens  alone  unless  the  advent  of  complications 
demands  its  removal.  In  the  rare  cases  where  the 
sclera  has  ruptured  and  the  lens  has  been  forced 
out  of  the  wound  and  under  the  conjunctiva  it  is 
better  to  remove  it  and  bring  the  scleral  wound 
together  either  by  scleral  stitches  or  by  anchoring 


TRAUMATIC  CATARACTS  39 

the  conjuncti\a  in  such  a  way  as  to  pull  the  wound 
together.  This  seems  much  better  than  leaving 
the  lens  until  the  scleral  wound  has  healed.  In 
the  cases  of  cataracts  due  to  perforating  injuries, 
as  a  rule  the  treatment  may  be  carried  out  at  the 
time  of  the  reparative  work  on  the  injured  eye, 
especially  if  the  lens  is  considerably  broken  up. 
For  operating  on  eyes  showing  a  swollen  traumatic 
cataract  the  following  procedure  is  advisable: 
Through  the  original  wound  if  it  still  be  open  or 
through  a  corneal  incision  made  with  the  keratome 
or  Graefe  knife  the  tip  of  the  suction  apparatus 
can  be  placed  inside  and  a  goodly  portion  of  the 
swollen  lens  substance  withdrawn.  In  doing  this 
one  must  make  sure  that  the  anterior  capsule  is 
well  open  and  retracted.  Otherwise  the  suction 
apparatus  will  not  take  up  the  lens  substance. 
The  removal  of  the  middle  of  the  anterior  lens 
capsule  by  means  of  capsule  forceps  is  advised. 
The  remaining  portions  of  the  lens  substance  can 
be  washed  out  with  the  irrigator  or  the  irrigator 
may  be  used  for  the  whole  operation  by  those  not 
wishing  to  use  the  suction  apparatus.  In  some 
cases  it  may  be  possible  to  remove  the  greater 
portion  of  the  lens  substance  by  massage  of  the 
cornea,  though  the  author  much  prefers  one  of 
the  foregoing  methods.  After  the  removal  of  the 
lens  substance  the  iris,  which  has  been  displaced  or 
extruded  during  the  procedure,  must  be  put  back 


40  MILITARY   OPHTHALMIC  SURGERY 

either  with  the  stream  of  water  from  the  irrigator 
or  a  repositor,  and  if  it  does  not  go  back  readily 
and  smoothly  an  iridectomy  should  be  performed. 
Atropin  both  before  and  after  the  operation  will 
help  to  prevent  adhesions  between  the  iris  and  the 
strands  of  lens  capsule.  Where  a  very  minute 
fragment  has  passed  through  the  lens  and  been 
removed  by  the  magnet  either  by  the  anterior  or 
the  posterior  method  the  lens  injury  may  safely  be 
disregarded,  for  in  some  cases  the  lenticular  opacity 
will  be  permanently  confined  to  the  part  of  the 
lens  through  which  the  fragment  has  passed. 

PENETRATING    WOUNDS    OF    THE    ORBIT. 

Here  again  the  treatment  will  depend  largely  on 
the  presence  or  absence  of  a  foreign  body.  Many 
of  the  bullet  wounds  involving  the  orbit  are  through 
and  through,  and  several  were  seen  by  the  author 
where  the  bullet  had  passed  through  the  apex  of 
both  orbits  from  side  to  side,  cutting  the  optic 
nerves.  Except  for  the  direct  injury  produced  and 
the  consequent  filling  of  the  orbit  with  blood  such 
through-and-through  bullet  wounds  are  usually  not 
attended  by  complications  in  healing,  unless  too 
great  a  degree  of  proptosis  results.  This  may  also 
be  true  of  the  round  lead  shrapnel  bullet,  which 
may  enter  the  orbit  without  causing  much  damage 
and  be  removed,  leaving  the  important  orbital  struc- 
tures intact   (Plate  II).     All  this,  however,  is  not 


^ 


PLATE    II 


X-ray  of  shrapnel  ball  which  entered  the  orbit  between 
the  eyeball  and  the  lacrimal  bone.  It  passed  just  behind  the 
eyeball  and   was  removed,   leaving  the  latter  uninjured. 


; 


PLATE    III 


X-ray  of  piece  of  brass  shell  timer  located  in  right  frontal 
sinus,  having  passed  through  the  left  eye  and  left  frontal 
sinus. 


J 


PENETK.\.TING  WOUNDS  OF  THE  ORBIT  41 

true  of  other  forms  of  missile,  especially  the  jagged 
l)ieces  of  shell  casing  which  are  very  likely  to  pro- 
duce an  orbital  cellulitis  that  may  be  caused  by  the 
Bacillus  aerogenes  capsulatus.  The  author  has  seen 
5  cases  of  such  gas-bacillus  infection  of  the  orbit, 
with  one  death.  Removal  of  the  offending  foreign 
substance  from  the  orbit  and  free  drainage,  with 
the  use  in  the  most  severe  cases  of  Carrell's  tubes, 
will  usually  take  care  of  orbital  cellulitis. 

Careful  localization  by  means  of  the  .T-ray  is  of 
first  importance  before  making  attempts  to  remove 
intra-ocular  foreign  bodies,  to  determine  whether 
they  have  passed  outside  of  the  orbit,  or  may  be 
intra-orbital.  In  many  cases  It  will  be  found  that 
they  have  passed  into  the  brain  cavity,  requiring 
a  craniectomy  for  their  removal.  For  such  cases 
a  specially  devised  brain  tip  for  the  arm  magnet 
may  be  of  signal  service.  Such  a  brain  tip  has 
been  previously  suggested  by  the  author  for  the 
Lancaster  arm  magnet  and  is  about  the  size  and 
shape  of  the  ordinary  blackboard  crayon.  P^oreign 
bodies  which  have  passed  through  the  orbit  may  also 
be  located  in  the  frontal  sinus  or  ethmoid  and  after 
.v-ray  localization  be  removed  (Plate  III).  Experi- 
ence has  shown  that  if  such  foreign  bodies  have 
passed  through  both  the  orbit  and  ethmoid  into  the 
brain  cavity  there  usually  results  a  fatal  meningitis. 
Two  of  the  author's  cases,  however,  where  the 
foreign  body  had  (lri\en  the  superior  orbital  plate 


y 


42  MILITARY   OPHTHALMIC   SURGERY 

upward  into  the  brain  cavity  were  followed  by 
recovery.  In  the  case  of  small  fragments  that  have 
passed  into  the  apex  of  the  orbit  where  attempts  at 
removal  might  endanger  the  muscles  and  nerves 
it  is  wiser  to  refrain  from  interference  unless  subse- 
quently an  orbital  cellulitis  develops,  though  it  is 
not  usual  for  small  fragments  to  penetrate  so  deeply. 
One  complication  deserves  especial  mention  here, 
for  prompt  treatment  may  result  in  saving  an  eye, 
or  possibly  an  only  eye.  This  refers  to  the  neuro- 
paralytic corneal  disturbances  resulting  from  an 
injury  to  the  orbital  nerves  and  the  corneal  disturb- 
ances due  to  exposure  where  an  orbital  hemor- 
rhage or  injury  has  caused  excessive  proptosis. 
These  two  conditions  usually  occur  together  and 
there  should  be  added  to  them  at  this  time  the 
cases  of  corneal  exposures  from  lagophthalmos  due 
to  an  injury  that  has  cut  the  facial  nerve.  The 
moment  the  cornea  shows  signs  of  loss  of  luster  or 
beginning  ulceration,  and  in  selected  cases  even 
before  the  signs  appear,  the  outer  two-thirds  of  the 
lids  should  be  sutured  together.  As  the  cases  may 
be  of  long  duration,  especially  those  with  lagoph- 
thalmus,  it  is  best  to  pare  the  outer  two-thirds  of 
both  lid  edges,  avoiding  the  lashes,  prior  to  suturing, 
so  that  they  may  remain  united  as  long  as  desired. 
This  procedure  leaves  a  small  lid  aperture  through 
which  the  eye  condition  may  be  observed  and 
treated  and  the  patient  see.     If  considerable  ulcer- 


PENETRATING  WOUNDS  OF  THE  ORBIT  43 

ation  of  the  cornea  has  already  appeared  at  the 
usual  position,  just  above  the  lower  limbus,  better 
and  quicker  healing  for  this  may  be  brought  about 
by  covering  the  lower  half  of  the  cornea  with  a 
conjunctival  flap  after  curetting  the  ulcer  and  rub- 
bing in  iodoform  or  tincture  of  iodin.  Subsequent 
iri-atment  depends  on  conditions  as  they  arise, 
Tiie  following  case  illustrates  the  above  very  well. 
Sergeant  H.  Entered  the  hospital  after  having 
been  hit  on  the  left  side  of  the  face  by  a  large  piece 
of  shell  which  fractured  both  the  upper  and  lower 
jaw,  with  multiple  cuts  in  the  parotid  region  extend- 
ing from  the  zygoma  down  to  the  angle  of  the  man- 
dible. There  was  a  good  deal  of  loss  of  tissue  in 
this  region  and  the  ear  was  badly  torn.  The  injury 
was  three  days  old  and  as  a  result  of  a  complete 
lagophthalmus  and  exposure  of  the  eye  there  was 
a  deep  corneal  ulcer  involving  the  lower  quarter  of 
the  cornea.  There  was  a  hypopyon  occupying  the 
lower  third  of  the  anterior  chamber  which  shifted 
on  the  patient  lying  on  his  side.  The  patient  was 
in  a  semiconscious  condition,  but  it  was  thought 
i)cst  to  make  an  attempt  to  save  the  eye.  The 
usual  conjunctival  flap  for  such  a  condition  was 
l^rcpared  and  the  outer  two-thirds  of  the  lid  edges 
were  pared  off,  then  the  ulcer  scraped,  the  anterior 
chamber  opened  and  the  pus  allowed  to  escape, 
iodoform  was  rubbed  in  and  the  conjunctival  flap 
drawn  up  over  the  lower  half  of  the  cornea.     The 


44  MILITARY   OPHTHALMIC  SURGERY 

prepared  portion  of  the  lids  were  then  sutured 
together,  White's  ointment  appHed  and  the  eye 
bandaged.  Twice  daily  after  this  the  conjunctival 
sac  was  washed  out  through  the  aperture  left 
between  the  lids  near  the  inner  canthus  and  atropin 
and  argyrol  instilled.  After  a  few  days  of  this  the 
conjunctival  flap  pulled  back,  showing  a  perfect 
healing  of  the  corneal  ulcer.  The  patient  left  the 
hospital  about  six  weeks  later  with  the  lids  still 
held  together  and  with  excellent  vision  through 
the  unsutured  portion,  the  pupil  fully  dilated  with 
atropin  and  the  cornea  showing  a  slight  hazy  cica- 
trix where  the  former  ulcer  had  been.  This  expe- 
rience was  repeated  a  number  of  times,  so  that  this 
procedure  can  certainly  be  recommended  in  these 
desperate  cases, 

[The  danger  of  injudicious  exploration  of  the 
orbital  tissues  and  the  tolerance  by  the  orbit  of 
foreign  bodies  have  been  described.  Sometimes 
deeply  situated  foreign  bodies  may  be  secured, 
after  x-ray  localization,  by  resection  of  the  temporal 
wall  of  the  orbit:  in  one  case  examined  by  the 
editor  the  body — a  piece  of  shrapnel — being  situ- 
ated just  at  the  apex  of  the  orbit  in  contact  with 
the  optic  nerve.] 


WOUNDS   OF    THE   EYELIDS. 


WOUNDS  OF  THE  EYELIDS 


In  this  war  sc\ere  wounds  of  tlie  face  ha\'e  been 
extremely  common  and  many  of  these  have  involved 
the  eyelids,  with  or  without  some  of  the  ocular 
wounds  described  abo\e.  In  some  cases  the  lids 
are  actually  torn  away  and  completely  destroyed, 
so  that  subsequently  careful  plastic  surgery  becomes 
necessary.  Pedicled  fiaps  may  be  used  provided 
there,  has  not  been  a  large  destruction  of  surround- 
ing skin  tissue.  Otherwise,  Thiersch  grafts  may  be 
employed.  No  definite  rules  of  procedure  can  l)e 
laid  down  because  the  cases  vary  so  much  and  each 
indixidual  case  must  be  treated  according  to  the 
conditions  and  along  the  lines  that  have  proved 
best  for  the  individual  operator.  Cuts  and  tears  of 
the  lids  where  the  loss  of  tissue  is  slight  or  absent 
should  be  carefully  sutured  as  early  as  possil)le. 
The  greatest  pains  must  be  taken  to  see  that  the 
conjunctival  portion  is  first  accurately  sutured 
and  that  the  line  of  the  lashes  be  restored  before 
suturing  the  skin  wound.  Tin's  is  no  less  true 
when  the  e>e  itself  is  destroyed,  for  in  such  a  case 
the  good  appearance  of  an  artificial  eye  may  depend 
on  the  accuracy  of  lid  suturing.  When  the  cuts 
are  multiple  the  usual  condition,  and  especially 
through  the  inner  canthus,  a  severe  test  is  put  on 
the  operator's  skill  and  patience.  For  the  conjunc- 
ti\  al  i)ortion  of  the  cut,  fine  silk  is  the  best  suturing 


J 


}<.  MILITARY   OPHTHALMIC  SURGERY 

material,  and  this  is  also  used  for  the  skin,  though 
one  may  substitute  horsehair,  silkworm  gut,  or 
catgut.  When  the  cut  extends  into  skin  beyond 
the  lids  silkworm  gut  affords  the  best  material. 
Owing  to  the  fact  that  many  of  these  lid  cases  have 
been  dealt  with  as  open  wounds  until  their  arrival 
at  the  Base  Hospital  it  is  necessary  that  the  wound 
edges  be  freshened  before  suturing.  If  subsequent 
infection  takes  place  and  the  wound  opens,  plastic 
surgery  becomes  necessary  later.  It  is  not  the 
purpose  in  this  chapter  to  enter  into  a  description 
of  plastic  work  for  restoration  of  lids  and  sockets, 
though  of  such  work  there  will  be  plenty  after  the 
war.  The  present  appeal  is  for  the  earliest  possible 
suturing  of  lid  wounds. 

PROPHYLAXIS. 

It  is  well  to  consider  at  this  time  the  best  method 
of  preventing  some  of  these  severe  eye  injuries,  and 
the  author  had  worked  out  a  tentative  plan  for  a 
steel  eye  shield  to  be  fastened  to  the  soldier's  helmet. 
On  taking  up  the  question  with  some  of  the  author- 
ities in  Washington  it  was  found  that  Colonel 
W.  H.  Wilmer  had,  at  the  request  of  the  Ordnance 
Department,  devised  a  shield  along  similar  lines 
and  one  that  left  very  little,  if  anything,  to  be 
desired  toward  accomplishing  its  purpose.  The 
author's  shield  had  two  stenopeic  slits,  one  hori- 


PROPHYLAXIS  47 

zontal  and  one  vertical,  while  Dr.  Wilmer's  has  a 
single  horizontal  stenopeic  slit  in  front  of  each  eye 
which  allows  for  good  vision,  greatly  enhances  the 
strength  of  the  shield  and  is  by  far  the  best.  By 
extending  the  shield  on  each  side  it  can  be  made  to 
cover  the  temple  region,  thus  including  the  outer 
ridge  of  the  orbit  and  the  malar  bone.  Such  a 
shield  if  fastened  to  the  helmet  so  that  it  can  be 
swung  up  out  of  the  way  when  not  in  use  would,  if 
the  soldiers  could  be  induced  to  wear  them,  lessen  to 
a  \ery  great  extent  the  number  of  eye  injuries.  A 
full  description  of  Colonel  Wilmer's  ingenious  device 
will  probably  be  written  by  him.  In  devising  such 
shields  with  a  single  stenopeic  slit,  the  closer  it  can 
be  brought  to  the  eyes  the  better.  The  question 
of  whether  it  is  advisable  to  make  the  eye  shield 
tight  enough  to  keep  out  lachrymatory  gases  by 
careful  f)adding  and  placing  some  transparent 
material  behind  the  opening  can  only  be  decided 
by  actual  experience.  Such  a  tight  shield  might 
cause  a  steaming  of  the  transparent  material  and 
prevent  its  use.  It  might  possibly  be  more  advis- 
able to  have  the  gas  mask  entirely  separate  from 
the  shield  and  make  no  attempts  to  keep  the  latter 
air-tight. 


48  MILITARY   OPHTHALMIC  SURGERY 

EYE    CONDITIONS   THAT   ARE   AN   EXPRESSION   OR 
DIAGNOSTIC  SIGN  OF  DISEASE  OR  INJURIES 
ELSEWHERE. 

Retinal  and  optic  nerve  alterations  may  be  found 
in  the  so-called  trench  nephritis.  To  see  these  signs 
at  their  height  one  must  examine  the  nephritis 
cases  as  soon  as  they  enter  the  hospital,  for  the 
slight  optic  neuritis  and  retinal  edema  seen  in  at 
least  75  per  cent,  of  the  severe  cases  is  very  ephem- 
eral and  subsides  as  rapidly  as  the  general  edema. 
Rarely  hemorrhages  may  be  seen  but  no  sign  of 
vessel  or  retinal  degeneration.  One  of  the  most 
important  services  of  the  ophthalmic  surgeon  lies 
in  his  examination  for  eye  signs  in  all  cranial 
injuries  whether  they  are  simple  concussions,  furrow 
wounds,  fractures  or  penetrating  wounds,  and  a 
load  of  responsibility  rests  upon  him,  for  the  general 
surgeon  frequently  bases  his  decision  as  to  oper- 
ating on  the  report  of  his  ophthalmic  confrere. 
Most  of  the  severe  local  head  blows  made  by 
glancing  bullets  or  shrapnel  balls  (the  so-called 
furrow  wounds),  or  an  impinging  but  not  penetrat- 
ing piece  of  shell  casing,  which  have  resulted  in 
splintering  of  the  inner  table,  or  the  brain  destruc- 
tion which  may  occur  without  any  splintering 
whatever,  will  sooner  or  later  give  rise  to  increased 
intracranial  pressure,  the  first  sign  of  which  is  a 
rapidly  developing  disk-edema  which  quickly  in- 
creases to  a  choking  of  the  disk.    In  these  cases 


EYE   CONDITIONS  49 

the  condition  from  the  start  is  of  the  choked  disk 
or  intracranial  pressure  type,  where  the  swelling 
is  confined  almost  wholly  to  the  nerve  head  even 
when  it  is  raised  several  diopters  above  the  sur- 
rounding retina.  This  type  of  optic  nerve  change 
can  thus  be  differentiated  from  the  inflammatory 
type  which  is  seen  in  the  cases  that  develop  menin- 
gitis. Here  besides  the  swollen  nerve  head  there 
is  an  extension  of  inflammatory  disturbance  for 
some  distance  out  into  the  retinal  tissue,  with  fre- 
quently hemorrhages  and  exudates.  Thus  it  is 
possible  in  some  cases  to  differentiate  between 
intracranial  pressure  and  meningitis  even  in  the 
early  stages  of  these  conditions.  When  the  nerve 
change  is  due  to  increased  intracranial  pressure  a 
trc'phining  over  the  injured  brain  area,  which  allows 
for  the  removal  of  an  extradural  or  intradural 
blood-clot  or  disorganized  brain  substance,  results 
ill  its  raj^id  disappearance.  A  recrudescence  of 
these  ner\e  conditions  would  indicate  a  return  of 
the  intracranial  pressure,  demanding  further  inter- 
fiTence.  When,  howev^er,  the  inflammatory  neu- 
ritis type  is  seen  it  usually  indicates  a  purulent 
meningitis  for  which  little  can  be  done.  For  the 
injuries  of  the  back  of  the  head  besides  a  fundus 
insjjection  there  should  be  a  careful  testing  of  the 
\isual  fields.  Such  an  examination  will  reveal 
many  cases  of  varying  types  of  hemianopsia  from 
the  complete  homonymous  hemianopsia  to  hemian- 
4 


50  MILITARY   OPHTHALMIC  SURGERY 

opic  scotomata  and  quadrant  defects.  Frequently 
it  will  be  found  in  the  long  furrow  wounds  across 
the  occipital  region  that  the  brain  lesion  as  shown 
by  the  hemianopsia  is  on  the  side  not  indicated  by 
the  most  severe  portion  of  the  scalp  injury.  For  a 
treatise  on  the  very  careful  working  out  of  such 
fields  the  reader  is  referred  to  an  excellent  one  by 
Holmes  and  Lister  {Proceedings  Royal  Society  Med- 
icine, June,  1916).  Some  of  the  hemianopsias  will 
recover  following  operative  interference,  but  some 
will  not.  When  the  hemianopsia  is  not  accom- 
panied by  optic  nerve  changes  and  there  are  no 
other  indications  for  operation  and  the  bone  unin- 
jured, operation  is  not  advised.  Various  paralyses 
of  the  third  and  sixth  ocular  nerves  may  result 
from  basal  fractures  and  are  interesting  from  the 
stand-point  of  localization,  but  have  no  special 
bearing  on  the  question  of  prognosis  or  treat- 
ment. 

[Almost  always  a  papillary  swelling  appearing 
soon  after  a  cranial  injury  indicates  a  developing 
choked  disk.  Disk  changes  occurring  at  a  later 
period  may  be  papillo-edemas  (choked  disks) 
caused,  for  example,  by  a  cyst,  or  papillitis  (optic 
neuritis)  in  association  with  brain  abscess  in  men- 
ingitis. Bilateral  choked  disks  which  arise  weeks 
and  months  after  cranial  injury  are  of  grave 
import  in  that  they  indicate  a  serious  intracranial 
lesion  which  has  escaped  notice.     Hence  the  impor- 


REFRACTION  51 

tance,  as  has  bccMi  pointed  out,  of  frequent  ophthal- 
moscopic examination  after  all  cranial  injuries.] 

PSYCHONEUROSES. 

It  is  not  within  the  scope  of  this  book  to  enter 
into  a  lengthy  discussion  as  to  the  various  forms 
of  psychoneuroses  which  often  accompany  the  so- 
called  shell  shock.  Many  cases  of  amblyopia  are 
obser\'ed  and  some  of  them  have  been  proved  to  be 
similar  to  the  hysterical  amblyopia  seen  in  civil  life. 
Some  soldiers  with  night-blindness  come  under  the 
same  category,  though  several  seen  showed  typical 
retinitis  pigmentosa  and  were  evidently  affected 
before  entering  the  service. 

REFRACTION. 

Each  Base  Hospital  should  have  a  trial  case  and 
frames  so  that  emergency  refraction  work  can  be 
done  for  officers  and  such  of  the  personnel  as  may 
require  it.  It  is,  however,  not  the  purpose  of  this 
book  to  go  into  the  subject  of  refraction.  When  a 
Special  Hospital  is  reasonably  near  the  Base  Hos- 
pital such  work  can  be  better  done  there.  A  full 
equipment  is  necessary  in  each  Base  Hospital  for 
performing  the  various  tests  for  detecting  malin- 
gerers. The  description  of  such  tests  by  Colonel 
Walter  R.  Parker  is  given  in  Section  III,  and  is 
very  complete. 


52  MILITARY   OPHTHALMIC  SURGERY 

From  my  experience  and  observations  while  doing 
the  eye  work  for  Base  Hospitals  aggregating  nearly 
ten  thousand  beds  I  have  become  firmly  convinced 
that  with  the  large  groups  of  Base  Hospitals  handy 
to  them  there  should  be  established  a  Special  Hos- 
pital so  that  men  with  seriously  wounded  eyes 
might  have  the  care  that  is  given  to  such  cases 
in  the  many  civilian  Special  Hospitals  found  so 
necessary  in  the  industrial  centers  in  this  country. 
The  more  remote  Base  Hospitals  are  from  the 
home  country  the  greater  the  need  of  a  Special 
Hospital  in  the  war  zone,  as  much  for  the  beginning 
of  reconstruction  work  as  for  the  acute  cases.  Men 
in  Field  Hospitals  whose  principal  injury  is  obvi- 
ously a  severe  one  of  the  eye  could  be  tagged  and 
sent  directly  to  the  Special  Hospital,  while  men  in 
Base  Hospitals  requiring  treatment  best  afforded 
by  the  Special  Hospital  could  be  transferred  in  a 
few  hours,  as  shown  by  actual  experience.  Such  a 
Special  Hospital  could  have  a  much  more  extensive 
equipment  than  the  average  Base  Hospital.  There 
should  be  an  operating  building  with  at  least  two 
operating  rooms,  one  for  the  infected  cases  and  one 
for  the  non-infected.  In  the  latter  various  types 
and  strengths  of  magnets  should  be  installed.  An 
x-ray  room  should  be  provided  and  placed  in 
charge  of  an  Officer  thoroughly  familiar  with  intra- 
ocular foreign-body  localization.  The  x-ray  oper- 
ator in   the  average   Base   Hospital   has  not   this 


REFRACTION  53 

familiarity  and  as  a  rule  has  not  the  time  to  develop 
such.  One  American  who  has  recently  published 
nearly  one  thousand  foreign-body  records  is  recog- 
nized as  one  of  the  finest  rontgenologists  and  for- 
eign-body localization  experts  in  the  world,  and  it 
would  certainly  seem  wasteful  to  ask  such  a  man 
to  take  care  of  the  few  cases  requiring  such  experi- 
ence that  would  come  to  the  average  Base  Hospital 
when  in  a  Special  Hospital  so  much  greater  use 
might  be  made  of  such  unusual  ability.  A  dark 
room  in  the  operating  building  is  necessary  for 
fundus  and  retinoscopic  work  and  some  of  the 
wards  should  be  arranged  so  that  they  could  be 
darkened.  A  long  vision  room  with  trial  cases  and 
all  the  equipment  necessary  for  the  best  refraction 
work  should  be  provided  and  one  or  more  expert 
opticians  with  all  the  tools  and  supplies  required 
to  grind  and  cut  out  lenses  and  adjust  frames.  A 
good  supply  of  already  cut  round  cylinders  and 
spherocylinders  could  be  carried  and  the  correct 
axes  be  obtained  by  simply  turning  them  in  the 
frames.  Lastly,  but  by  no  means  least,  the  nurses 
in  such  a  hospital  could  be  chosen  from  those  hav- 
ing special  training  in  some  of  the  Eye  and  Ear 
Hospitals.  Such  a  hospital  might  be  made  part  of 
a  Special  Hospital  for  head,  ear,  face,  and  jaw 
injuries,  there  being,  of  course,  great  need  for  early 
reconstruction  work  along  all  these  lines.  Some 
such  scheme  for  the  employment  of  special  men  has 


54  MILITARY   OPHTHALMIC   SURGERY 

for  some  time  been  followed  by  the  Continental 
Army  Medical  Departments  and  it  is  becoming 
more  evident  every  day  that  the  best  reconstruc- 
tion work  begins  as  soon  as  possible  after  a  soldier 
has  been  wounded,  and  in  no  line  of  surgery  is 
early  special  work  more  necessary  and  productive 
of  good  results  than  ophthalmic  surgery. 

It  has  been  impossible  in  a  condensed  account  of 
personal  experiences  like  this  to  cover  in  detail  all 
military  eye  work,  but  it  is  the  hope  of  the  author 
that  helpful  hints  may  be  found  in  it  for  the  oph- 
thalmic surgeons  who  go  fresh  from  civilian  practice 
into  Army  Hospital  work,  and  that  they  may  be 
stimulated  by  it  to  careful  attempts  to  do  conser- 
vative eye  surgery  for  the  soldiers  who  give  so 
much.  It  is  also  hoped  that,  from  the  above,  a 
realization  of  how  frequently  severe  multiple  eye 
injuries  occur  in  trench  warfare  and  how  impor- 
tant the  saving  of  sight  is,  both  to  the  soldier  and 
the  country,  may  stimulate  men  of  wide  ophthalmic 
experience  to  serve,  and  the  army  heads  entrusted 
with  the  lives  and  sight  of  soldiers  may  be  induced 
to  see  that  such  experienced  men  are  made  a\ail- 
able  for  the  wounded.  The  niceties  of  skill  and 
judgment  necessary  to  handle  the  multitude  of 
severe  cases  can,  however,  only  be  acquired  by 
actual  experience,  for  the  author  cannot  agree  with 
those  who  consider  that  military  ophthalmology 
differs  from  civilian  only  in  degree  but  not  in  kind. 


AR^[Y   CASE   OF   EYE   INSTRUMENTS  55 

How  many  civilian  ophthalmic  surgeons,  if  any, 
have  treated  gas-bacillus  infections  of  the  orbit 
and  face,  and  how  many  have  treated  eye  and 
orbital  injuries  due  to  high-velocity  bullets?  In 
reality  there  are  many  eye  conditions  seen  which 
are  entirely  new  even  to  men  of  large  experience 
in  industrial  accidents. 

The  following  list  'of  instruments  necessary  for  a 
Base  Hospital  is  here  included: 


Army  Case  of  Eye  Instruments.     Model  of  191 7. 
(In  Mahogany  Case.) 

Quantity. 

Curette,  chalazion  (Mayhoefer),  medium i 

Cystotome  (Graefe) i 

Canahculus  knife  (Bowman),  fle.xible  shank 2 

Forceps,  advancement  (Reese's) i 

Forceps,  cilia,  plain i 

Forceps,  chalazion  (Lambert's) i 

Forceps,  entropion  (Desmarres) i 

Forceps,  fixation  with  catch 2 

Forceps,  iris,  angular,  mouse-toothed 2 

Forceps,  trachoma  (Noyes's),  i  up  and  i  down 2 

Forceps,  trachoma  (Prince's) i 

Gouge,  sharp-pointed,  V-shaped i 

Iris  hook,  sharp  (Tyrell's) i 

Iris  scissors,  full  curved 2 

Knives,  cataract  (Graef's),  assorted  sizes 3 

Irrigator,  anterior  chamber i 

Knives,  scalpel  type,  medium  size 3 

Knives,  needle  (Knapp's),  medium  size 3 

Keratome,  angular  (Jaeger's),  medium  size 3 

Lens,  spoon,  metal  (Graefe's) i 

Lens,  spoon,  metal  (Daviel's) i 

Lens,  condensing,  2  inches  broad,  hard-rubber  ring i 

Lid  plate,  hard  rubber  (Jaeger's) i 


56  MILITARY   OPHTHALMIC  SURGERY 

Quantity. 

Needle-holding  forceps  (Stevens's) 2 

Lens,  spoon,  wire  loupe i 

Needles,  paracentesis i 

Needles,  full  curved,  plain  eye,  cutting  edge 12 

Needles,  half  curved,  plain  eye,  cutting  edge,  assorted 12 

Ophthalmoscope  (Loring's) i 

Probes,  lachrymal  (Theobold's),  double-ended  (set) i 

Retinoscope i 


Auxiliary  Case. 

Cautery  handle. 

Cautery  tips  (corneal  set). 

Lachrymal  (canaliculus)  dilator. 

Fixation  forceps  (without  catch). 

Iris  forceps  (curved  2,  straight  i). 

Capsule  forceps. 

Trachoma  forceps  (Knapp's). 

Advancement  forceps  (Prince's). 

Entropion  forceps  (right  and  left  angular) . 

Lid  elevator,  i  additional. 

Keratomes,  straight. 

Knife,  cataract  (Graefe's),  3  additional. 

Knife  (Beer's). 

Knife,  scalpel  type,  3  additional. 

Knife,  needle  (Hays-Ziegler). 

Needle  holder. 

Additional  needles,  2  dozen  curved. 

Scissors,  straight,  sharp-pointed. 

Scissors,  straight,  dull-pointed. 

Scissors,  half  curved. 

I  speculum,  additional  (Weeks's). 

I  spud,  protecting  handle. 

Tenotomy  hook  (Smith's). 

Tonotomy  hook  (Graefe's)  additional. 

Trephine  (Elliot's). 


ADDITIONAL  EQUIPMENT  NOT  TO  GO  IN  CASE        57 


Additional  Equipment  not  to  go  in  Case. 

12  soft-rubber  ear  syringes. 

I  DeZeng  box,  with  electric  ophthalmoscope  and  retinoscope. 

1  hand  perimeter  (Schweigger's),  with  12  dozen  charts. 

2  magnets  (Lancaster  models),  Thomas  Gleeson,  Boston. 

2  pocket  flashlights,  with  extra  batteries. 

1  corneal  loupe  (Berger's). 

3  irrigators  (Xew  York  Eye  and  Ear  Pattern). 
Suction  apparatus. 

Glass  balls  (i8,  20,  22  mm.,  12  each,  lead  free). 

Projection  lamp  for  illumination  in  eye  operating. 

Apparatus  for  localizing  foreign  bodies  (Sweet). 

Holgrem's  stick  of  colored  worsteds. 

Tonometer  (SchiOtz's). 

Treatment  case. 

Set  of  non-magnetic  instruments. 

Instrument  rack. 

Undines,  12. 

2  solution  bottles. 

2  condensing  lenses. 
I  wall  cabinet. 


7 


APPENDIX. 

INDICATIONS  FOR  ENUCLEATION. ^ 

1.  An  eye  with  a  wound  so  situated  as  to  invoKe 
the  ciHary  region,  and  so  extensive  as  to  destroy 
sight  immediately  or  to  make  its  ultimate  destruc- 
tion by  inflammation  of  the  iris  and  ciliary  body 
reasonably  certain. 

2.  An  eye  with  a  wound  in  this  region  already 
complicated  by  severe  inflammation  of  the  iris  or 
ciliary  body,  even  if  sight  is  not  destroyed;  or  an 
eye  containing  a  foreign  body  which  judicious 
eft'orts  have  failed  to  extract,  and  in  which  severe 
iritis  is  present,  even  if  sight  is  not  destroyed. 

3.  An  eye  the  vision  of  which  has  been  destroyed 
by  plastic  iridocyclitis,  or  one  which  has  atrophied 
or  shrunken,  provided  there  are  tenderness  on 
[)rt>>uri'  ill  the  ciliary  region  and  attacks  of  recurring 
irritation;  or  without  waiting  for  signs  of  irritation. 

4.  An  eye  the  sight  of  which  has  been  destroyed, 
even  though  sympathetic  inflammation  has  begun 

'  From  Manual  of  Opluhalmolog>',  prepared  by  the  Sub-section  <jf 
Ophthalmology,  Section  of  Surgery  of  the  Head,  Office  of  Surgeon- 
General,  War  Department,  Washington. 

(59) 


60  APPENDIX 

in  the  sympathizing  eye,  in  the  hope  of  removing  a 
source  of  irritation,  and  thus  rendering  treatment 
to  the  second  eye  more  effectual. 

5.  An  eye  in  which  the  wound  has  involved  the 
cornea,  iris,  or  ciliary  region,  either  with  or  without 
injury  to  the  lens,  and  in  which  persistent  sym- 
pathetic irritation  in  the  fellow  eye  has  occurred, 
or  in  which  there  have  been  repeated  relapses  of 
sympathetic  irritation. 

6.  An  eye  either  primarily  lost  by  injury  or  in 
a  state  of  atrophy  associated  with  signs  of  sympa- 
thetic irritation  in  the  fellow  eye. 


INDICATIONS  FOR  EVISCERATION. 

Evisceration  should  be  substituted  for  enucleation : 

1.  When  there  is  an  infected  eye  with  infection 
of  the  surrounding  orbital  tissues. 

2.  When  there  is  a  panophthalmitis  following  a 
perforating  wound  and  the  wound  is  still  open  and 
extruding  infected  material. 

3.  When  the  eye  has  been  partly  eviscerated  by 
a  passing  bullet  or  fragment  of  shell. 

4.  When  the  patient  is  in  extremis  and  a  hopelessly 
torn  eye  must  be  treated  with  the  greatest  speed. 


TR.ACHOMA  AND  COMMON   FORMS  OF 
CONJUNCTIVITIS;  GAS  CONJUNC- 
TIVITIS. 

By  G.  E.  de  Schweinitz,  M.D., 

LIEUT.-COLONEL,  M.  C,  U.  S.  A. 

History. — Trachoma  is  of  ancient  lineage.  It 
is  referred  to  in  tlie  Ebers  Papyrus,  the  oldest 
medical  book  on  record,  written  during  the  height 
of  Egyptian  civilization,  therefore  1553  B.C.,  and 
more  than  one  thousand  years  before  Hippocrates 
flourished.  Its  description  finds  place  in  the 
pseudo-Hippocratic  manuscripts  (460  B.C.),  and  it 
was  well  depicted  by  Celsus  in  the  time  of  Christ. 
Pr()l)ably  known  to  the  ancient  civilization  of  India 
and  China,  it  certainly  was  familiar  to  the  Greeks 
and  Romans,  and,  as  Boldt  points  out,  is  men- 
tioned in  the  Comedies  of  Aristophanes  (431  B.C.). 
Although  trachoma  existed  in  Egypt  in  early  days, 
its  widespread  evil  influence  in  this  country  is  not 
definitely  described  until  about  the  middle  of  the 
fifteenth  century,  and  one  hundred  years  later  the 
affection  had  become  pandemic,  and  this  hold  it 
has  retained  until  the  present  day.  Originally 
known  as  "ophthalmia"  or  "lippitudo,"  the  word 
trachoma  appears  first  in  the  writings  of  Pedannius 

(Gl) 


62  MILITARY   OPHTHALMIC  SURGERY 

Dioscordes  (60  a.d.).  The  term  "Egyptian  oph- 
thalmia" came  into  existence  after  Napoleon's 
Egyptian  campaign  (1798),  from  which  time,  to 
quote  Boldt,  there  dates  a  new  era,  pregnant  with 
evil,  for  the  Continent  of  Europe,  although  the 
disease  in  this  area  had  been  endemic  from  time 
immemorial.  At  what  period  trachoma  invaded 
our  own  country  is  unknown.  It  may  have  been 
introduced  during  Colonial  days,  or  in  the  tide  of 
immigration  at  a  later  period. 

Distribution. — The  dissemination  of  trachoma 
in  Europe  became  noteworthy  after  the  return  of 
Napoleon's  soldiers  from  Egypt,  inasmuch  as  75 
per  cent,  of  them  had  been  infected.  They  came 
repeatedly  in  contact  with  each  other  and  with 
the  civil  population,  and  thus  spread  the  disease, 
often  in  epidemic  virulence.  In  the  English  Army 
in  1818  more  than  5000  soldiers  practically  lost 
their  sight  by  reason  of  this  disease;  in  1813-1819, 
in  the  Prussian  Armies,  20,000  to  30,000  were 
placed  on  the  invalid  list  because  of  it;  and  in  the 
Russian  Armies  from  1 816-1839,  76,811  men  were 
found  to  be  its  subjects;  while  in  Belgium  in  1840 
one  out  of  five  men  in  the  army  was  attacked 
(Fuchs).  Although  in  our  time  such  epidemics 
have  almost  ceased,  with  few  exceptions,  for 
instance,  in  Russia,  and  although  in  foreign  army 
life  the  proportion  of  trachoma  has  greatly  lessened, 
the  menace  of  this  disease  remains  in  these  circum- 


TIL4.CH0MA  G:} 

stances  most  conspicuous.  Puscaria,  quoted  l)y 
Duane,  reports  in  1900  that  almost  16  per  cent,  of 
the  Roumanian  Army  were  affected. 

In  the  present  war  several  epidemics,  controlled 
with  difficulty,  have  been  recorded,  and  trachoma 
among  alien  laborers  at  the  Western  front  has  at 
times  presented  the  British  with  a  serious  problem, 
which,  however,  has  been  admirably  solved.  Thus 
Major  T.  F.  Cunningham  and  Captain  J.  Wharton, 
of  the  British  Expeditionary  Force,  report  that 
19  per  cent,  of  the  Egyptians  brought  into  France 
had  active  trachoma  and  9  per  cent,  of  the  Chinese. 
The  infected  cases  were  isolated  and  the  disease 
was  not  transmitted  to  the  troops  or  civilian  popu- 
lation. 

In  the  early  portion  of  the  nineteenth  century 
trachoma  foimd  in  ci\il  life  a  fa\orable  soil  for 
its  dissemination  in  jails,  asylums  and  wherever 
inhabitants  of  the  poorer  classes  dwelt  together  in 
close  contact,  and  at  this  time  in  many  pauper 
schools  every  inmate  was  affected.  The  acute 
course  which  the  disease  manifested  at  this  period 
of  its  history  was  doubtless  due  to  mixed  infection, 
and  such  epidemics  have  in  great  measure  disap- 
peared. Nevertheless,  trachoma  remains  endemic 
in  many  lands;  it  is,  indeed,  a  world  disease.  It  is 
most  frequent  in  Arabia  and  Palestine,  and  in 
Egypt  it  is  generalized,  fully  95  per  cent,  of  the 
population  being  affected  (MacCallan).    Trachoma 


64  MILITARY   OPHTHALMIC  SURGERY 

is  endemic  in  Syria,  Persia,  Central  Asia,  China 
and  Japan.  Exceedingly  prevalent  in  Eastern 
Europe,  especially  in  Gallipoli,  Poland,  Lithuania, 
Russia,  Hungary  and  certain  districts  in  Prussia, 
it  is  noteworthy  that  Jews  of  inferior  social  grade 
are  prone  to  be  affected.  It  is  frequent  among 
Italians  of  the  lower  orders,  especially  in  the  south 
of  Italy.  In  England  "trachoma  is  an  alien  dis- 
ease, imported  by  aliens,  propagated  by  aliens  and 
handed  on  to  the  native  population  by  aliens" 
(Parsons);  in  Ireland  it  is  common  among  the 
poorer  classes. 

The  menace  of  trachoma  on  our  own  shores  is 
one  of  the  serious  problems  of  our  Immigration 
Officers.  Thus  the  number  of  aliens  entering  the 
port  of  New  York  during  the  fiscal  year  1908- 1909 
was  724,757,  among  whom  1083  cases  of  trachoma 
were  discovered.  Aliens  to  the  number  of  481,270 
were  inspected  and  certified  at  all  ports  in  the 
United  States,  its  dependencies  and  in  Canada 
during  191 6,  among  whom  920  trachoma  cases 
were  discovered.^  It  is  common  among  native 
Americans  in  certain  portions  of  our  own  country, 
moreover,  in  severe  and  destructive  manifestation, 
especially  in  definite  areas  in  Illinois,  in  the  moun- 
tainous regions  of  Kentucky  and  West  Virginia, 
and  is  particularly  noteworthy,   according  to  the 

1  There  has  been  a  marked  restriction  of  immigration  during  the  past 
four  years,  owing  to  the  European  War. 


TRACHOMA  65 

a(lniiral)lc  researches  of  Dr.  Stucky  and  of  Dr.  Jolm 
McMuUen,  of  the  United  States  PubHc  Health 
Service,  in  the  neighborhood  of  the  junction 
of  Kentucky,  Tennessee  and  the  Virginias.^  In 
States  where  high  winds  prevail  and  there  is  much 
irritating  alkaline  dust,  e.  g.,  in  Oklahoma,  Arkansas, 
Te.xas,  Arizona  and  New  Mexico,  trachoma  is  very 
pre\alent.  To  the  prevalence  of  trachoma  among 
the  Indians  of  our  country  much  attention  has  been 
paid,  with  encouraging  results.  The  annual  reports 
of  the  Commissioner  of  Indian  Affairs  since  191 1 
show  an  estimated  percentage  of  trachoma  never 
higher  than  20.44  P^^  cent.  This  percentage  has 
gradually  been  reduced  until  in  the  last  annual 
report  the  percentage  of  estimated  trachoma  is  17 
per  cent.,  based  on  a  population  of  194,824. 

A  certain  racial  predisposition  to  trachoma  has 
been  maintained,  the  Mongolian  race  being  espe- 
cially liable;  but  throughout  Asia  the  disease  is  no 
respector  of  race,  the  Aryan,  Semitic  and  Mon- 
golian suffering  with  equal  and  terrible  frequency. 
Although  the  negro  may  have  a  certain  resistance 
to  trachoma,  his  exemption,  at  one  time  insisted 
upon  by  Burnett  and  others,  is  certainly  not  cor- 
rect, as  is  shown  by  Minor  and  White,  and  the 
author  has  observed  a  number  of  cases  in  a  large 

'  During  the  fiscal  year  1915  -16  the  daily  attendance  at  five  trachoma 
hospitals  established  by  the  Public  Health  Service,  three  in  Kentucky 
and  one  each  in  Virginia  and  West  Virginia,  was  19,530. 
5 


66  MILITARY   OPHTHALMIC  SURGERY 

experience  in  the  Philadelphia  General  Hospital, 
although  he  cannot  be  sure  that  these  negroes  were 
of  pure  blood. 

A  climatic  predisposition  is  more  than  doubtful, 
although  it  has  been  found  that  dwellers  in  certain 
regions  of  the  earth  where  the  climate  is  damp  are 
readily  affected.  While  it  has  been  maintained 
that  an  altitude  of  more  than  a  thousand  feet  con- 
fers a  comparative  immunity  from  the  disease  and 
facilitates  its  cure,  and  while  this  appears  to  be  true 
in  Switzerland  and  the  Tyrol,  certainly  in  our  own 
country  no  such  influence  of  altitude  is  evident. 
D.  W.  White  has  found  and  studied  the  disease 
8000  feet  above  sea  level. 

Situation  of  the  Lesions  of  the  Disease. — 
The  thin  skin  of  the  eyelids  is  loosely  attached  to 
the  underlying  structures  by  a  delicate  connective 
tissue  which  is  free  from  fat,  hence  the  ease  with 
which  they  are  wrinkled  and  shifted.  To  give  the 
lids  shape  and  support  the  so-called  tarsal  cartilages 
are  supplied.  These  structures,  however,  do  not 
contain  cartilage  but  are  composed  of  a  firm  con- 
nective tissue.  The  tarsus  of  the  upper  lid  is  larger 
and  higher  than  that  of  the  lower  lid.  The  convex 
border  of  each  tarsus  is  attached;  its  other  border 
is  free.  ITpon  the  anterior  surface  of  the  tarsus 
lie  the  fibers  of  the  orbicularis  muscle;  its  posterior 
surface  is  covered  with  conjunctiva.  The  tendon 
of  the  levator  palpebrae  superioris  is  attached  to 


TRACHOMA  G7 

the  anterior  surface  of  the  tarsus  of  the  upper  Hd. 
To  each  tarsus  there  are  also  attached  certain 
smooth  muscle  fibers  known  as  the  superior  and 
inferior  tarsal  muscles.  From  the  convex  border 
of  each  tarsus  a  fascia  proceeds  to  the  margin  of 
the  orbit  and  on  each  side  joins  the  palpebral  liga- 
ments. This  is  the  orbitotarsal  fascia,  and  it,  the 
two  tarsi  and  the  palpebral  ligament  form  the 
orbital  septum. 

The  mucous  membrane  which  co\'ers  the  pos- 
terior surface  of  the  eyelids  and  the  anterior  sur- 
face of  the  eyeball,  ordinarily  known  as  the  con- 
junctiva for  convenience  of  description,  is  divided 
into  that  portion  closely  adhering  to  the  tarsus 
which  lines  the  under  surface  of  the  lids,  named  the 
tarsal  or  palpebral  conjunctiva,  that  portion  which 
spreads  over  the  ocular  globe,  named  the  bulbar 
conjunctiva,  and  that  portion  which  is  a  transitional 
fold  connecting  the  two  divisions  just  described, 
named  the  conjunctiva  of  the  fornix.  When  the  lids 
are  coapted  a  closed  sac  is  formed,  named  the 
conjunctival  cul-de-sac,  the  bottom  of  which  is  this 
fornix.  Should  the  conjunctiva  in  its  entirety 
be  dissected  carefully  from  its  attachments"  it 
would  form  a  sheet  of  mucous  membrane  approxi- 
iiKiiing  in  size  the  surface  of  the  palm  of  the 
hand. 

The  conjunctiva  of  the  lids  and  fornix  is  covered 
with    two   la\ers   of   epithelium    in    which   superfi- 


68  MILITARY   OPHTHALMIC  SURGERY 

daily  the  cells  are  cylindrical,  while  deeper  they 
are  flattened;  the  conjunctiva  of  the  scleral  expanse 
is  covered  with  laminated  pavement  epithelium, 
and  this  bulbar  conjunctiva  is  connected  with  the 
globe  by  a  loose  connective  tissue  known  as  epi- 
scleral tissue.  At  the  inner  angle  of  the  eye  the 
scleral  conjunctiva  is  duplicated  in  a  crescentic 
manner  to  form  the  semilunar  fold  or  plica,  at  the 
inner  side  of  which  is  the  small  red  mass  known  as 
the  caruncle,  which  has  the  histological  character- 
istics of  skin. 

The  bulbar  conjunctiva,  its  character  being  some- 
what changed,  continues  over  the  cornea,  forming 
its  uppermost  epithelial  layer,  beneath  which  is 
Bowman's  membrane.  At  the  periphery  of  the 
cornea  a  well-defined  edge  is  formed,  known  as  the 
limhus.  The  conjunctiva  of  the  transitional  or 
retrotarsal  fold  is  very  lax  and  lies  in  horizontal 
folds,  as  can  be  seen  if  after  the  lid  is  everted  a 
probe  is  passed  between  the  eyebrow  and  the  turned 
lid,  and  the  skin  pushed  down  until  the  fold  comes 
into  view. 

In  the  palpebral  conjunctiva  minute  elevations, 
called  papillcB,  are  found,  over  which,  however,  the 
epithelium  passes  evenly,  so  that  the  surface  is 
smooth.  They  are  larger  as  the  upper  border  of 
the  tarsus  is  reached.  True  papillae  in  the  form 
of  finger-like  extensions  of  the  substantia  propria 
with  epithelium   in   the   interstices  are,  according 


TRACnO\fA  G9 

to  Parsons,  found  only,  and  then  very  sparsely,  at 
the  limbus.  The  so-called  papilLie  of  the  lid  conr 
jiinctiva  vary  greatly  in  different  individuals  and 
increase  markedly  in  pathological  conditions.  Cer- 
tain depressions  in  the  conjunctival  surface  lined 
with  cylindrical  epithelium  are  usually  called 
Henle's  glands,  but  they  are  the  result  of  minute 
folds  and  are  not  of  glandular  structure. 

The  mucous  membrane  proper,  substantia  pro- 
pria, lying  l)elo\v  the  epithelium,  consists  of  adenoid 
connective  tissue.  In  its  meshes  are  many  lympho- 
cytes, often  freely  and  regularly  distributed;  nod- 
ules of  these  lymphocytes  are  frequently  formed, 
which  should  probably  not  be  regarded  as  true 
follicles,  although  in  this  regard  there  is  much 
dispute.  In  their  pathological  development  they 
increase  greatly  in  size  and  number.  Plasma  cells 
in  small  quantities  are  also  present  in  the  substantia 
propria;  its  deeper  layers  are  fibrous  and  are  less 
readily  infiltrated  with  cells.  In  this  conjunctiva 
and  sec(Midarily  in  the  tarsus  the  lesions  of  trachoma 
find  their  habitat,  and  because  their  interpretation, 
both  from  the  clinical  and  pathological  stand- 
points, can  be  more  readily  made  if  the  distribution 
and  structure  of  the  conjunctival  mucous  mem- 
brane and  tarsus  are  kept  in  mind,  this  brief  review 
of  their  component  parts  has  been  introduced. 

Definition. — Clinically,  trachoma  may  be  de- 
fined as  a  disease  the  essential  nature  of  which 


70  MILITARY   OPHTHALMIC  SURGERY 

depends  upon  a  chronic  inflammatory  infiltration 
and  hypertrophy  of  the  conjunctiva,  terminating, 
after  absorption  and  metamorphosis  of  this  inflam- 
matory material,  in  cicatricial  changes. 

From  the  pathologico-anatomical  stand-point 
trachoma  should  be  regarded  as  a  chronic,  deep 
and  often  densely  produced  lymphoid  infiltration 
of  the  conjunctiva  and  tarsus,  in  which  this  lym- 
phoid infiltration  is  sometimes  manifested  in  a 
diffuse  form  and  sometimes  by  circumscribed  col- 
lections of  cells  which  are  known  as  "follicles."' 
This  morbid  process  leads  to  destruction  of  the 
conjunctiva  and  as  has  been  noted  in  the  clinical 
definition  to  the  development  of  scar  tissue.  Dur- 
ing certain  stages  of  the  disease  there  may  be  more  \ 
or  less,  often  quite  profuse,  abnormal  secretion 
from  the  conjunctiva,  with  which  the  spread  of  the 
infection  is  intimately  connected. 

Clinical  Varieties  of  Trachoma. — Although 
at  one  time  it  was  customary  to  divide  trachoma 
into  acute  granular  conjunctivitis  and  chronic  granu- 
lar conjunctivitis,  and  although  this  distinction  is 
still  maintained  by  certain  authors,  and  although 
apparently  an  acute  trachoma  has  been  produced 
experimentally,   there   is   every   reason   to   believe 

'  These  follicles  are  also  known  as  "gianulations" — a  term  which 
must  not  be  confounded  with  the  small  fleshy  masses  which  form  in 
wounds — and  as  "trachoma  bodies"  (an  unfortunate  terminology).  The 
same  name  is  given  by  some  authors  to  the  Prowazek  bodies,  which  are 
described  on  page  77. 


PLATE    IV 


it- 


*^ 


Chronic  Trachoma  of  the  PaiDillary  Type; 
Beginning  Cicatrization. 


TRACHOMA  71 

that  these  so-called  acute  cases  represent  an  admix- 
ture of  ordinar>'  "glandular"  lids  and  acute  con- 
junctival catarrh.  Indeed,  an  attack  of  acute 
:onjunctivitis  may  precede  the  development  of  tra- 
:homa,  or  the  active  or  acute  manifestations  may 
be  due  to  an  infection  with  the  Morax-Axenfeld 
bacillus,  the  Koch-Weeks  bacillus  and  even  the 
^onococcus.  This  is  especially  true  in  Egypt. 
Moreover,  trachoma  is  essentially  a  disease  of 
exacerbation,  during  which  the  process  may  be  so 
active  that  it  simulates  the  primary  acute  disease. 

Chronic  Trachoma.  —  Chronic  trachoma  as 
originally  defined  is  conveniently  classified  into 
several  varieties. 

I.  Papillary  trachoma  is  characterized  in  typical 
:ases  by  an  infiltration  of  the  adenoid  layer,  which 
rushes  up  the  thickened  epithelium  and  by  hyper- 
:rophied  and  congested  conjunctival  papilUc  which 
nake  it  difficult  or  impossible  to  detect  the  "swollen 
ollicles"  (trachoma  bodies).  The  appearances  arc 
lot  unlike  a  chronic  conjunctivitis  of  the  non- 
Tachomatous  type,  and  the  thickening  and  redness 
)f  the  tissue  may  be  so  great  that  it  somewhat 
•esembles  raw  beef.  To  this  form  of  the  disease  the 
:erni  chronic  trachoma  is  often  specially  applied. 
iVhere  the  follicles  (trachoma  bodies)  can  be 
ietected  lying  among  the  greatly  hypertrophied 
md  inflamed  papillse  the  process  is  sometimes 
lescribed  as  diffuse  or  mixed  trachoma.     (Plate  IV.) 


72  ,  MILITARY   OPHTHALMIC   SURGERY 

2.  Follicular  trachoma  is  characterized  by  con- 
spicuous development  of  grayish-white  or  yellowish- 
red  follicles  in  the  fornices,  often  in  rows  along  the 
upper  margin  of  the  superior  tarsus,  or  irregularly 
placed  in  the  tarsal  conjunctiva,  and  not  infre- 
quently invading  the  ocular  conjunctiva  and  even 
the  caruncle  and  plica.  From  fancied  resemblances 
they  have  been  called  "sage-grain"  or  "vesicular" 
granulation,  and  have  sometimes  been  likened  to 
the  appearance  of  frog-spawn.     (Plate  V.) 

3.  Cicatricial  trachoma  is  characterized  by  the 
formation  of  grayish-white  scar  lines,  often  inter- 
secting the  remains  of  old  granulations,  and  later  by 
diffuse  scar  tissue,  atrophy  and  fibroid  induration 
of  the  mucous  membrane.      (Plate  VI.) 

Symptoms  and  Course  of  Trachoma. — In  gen- 
eral terms  the  course  may  be  divided  into  the 
stage  of  evolution,  the  stage  of  elaboration  and  the 
stage  of  cicatrization.  Important  to  remember  is 
the  fact  that  the  lesions  may  develop,  especially 
in  the  upper  retrotarsal  folds,  without  antecedent 
inflammation,  and  so  insidiously  that  their  real 
nature  is  for  a  long  time  unknown  to  the  patient, 
and  undetected  unless  the  lids  are  carefully  in-  ; 
spected  after  thorough  eversion.  At  this  time  I 
there  may  be  little  or  no  abnormal  secretion.  Later 
the  palpebral  mucous  membrane,  often  yellowish 
red  in  color,  becomes  unevenly  rough  because  the 
tissue  is  filled  with   the  growing  and  developing 


PLATE    V 


.^0^W:  '^^^H 


Follicular  Trachoma. 


J 


^\ 


PLATE    VI 


•i^ 


"t 


Cicatricial  Trachoma  and  Pannus. 


^ 


TRACHOMA  73 

'follicles."  Even  in  this  period,  if  the  orginal 
)rocess  has  not  been  an  acutely  active  one,  abnormal 
ccretion  may  not  be  conspicuous. 

Still  later  the  follicular  and  cellular  masses  com- 
)ress  the  conjunctiva  and  its  circulation  and  corneal 
;hanges  become  manifest  in  the  beginnings  of  the 
io-called  pannus  (see  page  74).  As  time  goes  on 
/ascularit>'  increases,  the  follicles  grow  in  size  and 
ncrease  in  number,  their  contents  may  be  forced 
)ut  by  surrounding  infiltration  and  the  hypertro- 
phy of  the  so-called  conjuncti\al  papilke  becomes 
1  conspicuous  feature.  During  this  process  of  fatty 
degeneration  and  softening  of  the  follicles,  or  of 
-etrogression  without  softening,  fresh  eruptions  of 
'ollicles  are  taking  place,  which  in  turn  go  through 
the  same  changes  which  their  forerunners  have 
experienced.  The  conjunctiva  is  swollen,  the 
)apillcT  greatly  hypertrophied  and  the  follicles 
ire  hard  to  find;  indeed,  they  may  be  fused  with 
lapilla?.  The  mucous  membrane  assumes  a  fiesh- 
-ed  appearance,  photoj)hobia  is  active,  muco- 
:)urulent  or  purulent  secretion  is  abundant  and 
orneal  changes  are  consjMcuous.  These  \arious 
itages  may  last  for  months,  but  ultimately  invari- 
ibly  trachoma  results  in  cicatrization  as  the  result 
)f  absorption  of  the  contents  of  the  follicles  and 
proliferation  of  the  connective  tissue  of  the  con- 
unctiva. 

Although  it  is  con\  enicnt  to  di\i(le  the  course  of 


74  MILITARY  OPHTHALMIC  SURGERY 

this  disease  into  stages,  it  is  by  no  means  always 
possible  to  separate  sharply  one  from  the  other 
by  symptoms  or  manifestations  peculiar  to  itself. 
Exacerbations  are  frequent,  and  these  have  given 
rise  to  the  description  of  acute  trachoma,  because 
the  irritative  phenomena  become  intense,  with 
scalding  tears,  great  dread  of  light,  corneal 
vascularization,  ulceration  and  later  mucopurulent 
discharge. 

To  one  of  the  important  complications  of  tra- 
choma a  brief  reference  has  already  been  made, 
namely,  pannus.  Usually  stated  to  be  the  result 
of  long-standing  granular  lids,  in  its  earliest 
stages  it  is  often  found  soon  after  the  follicular 
infiltration  begins.  It  is  a  form  of  vascular  kera- 
titis, and  while  the  rough  upper  lid  is  a  predispos- 
ing factor,  it  is  not  the  true  cause  of  pannus,  which 
is  probably  due  to  contiguity  and  represents  a 
form  of  direct  infection.  Usually  the  upper  half  of 
the  cornea  becomes  hazy  and  small  vessels  proceed 
inward  from  the  corneal  loop  toward  the  center. 
At  first  they  lie  between  the  epithelium  and  Bow- 
man's membrane,  but  in  the  later  stages  this  mem- 
brane breaks  down  and  the  anterior  layers  of  the 
substantia  propria  are  involved.  Pannus  does  not 
always  begin  in  the  upper  portion  of  the  cornea. 
It  has  been  noted,  for  example  by  White,  as  com- 
mencing at  the  outer  half,  and  in  severe  types  the 
entire  cornea  is  invaded.     (Plate  VII.) 


PLATE   VII 


m 


Typical  Tiachoma. 


TRACHOMA  75 

\Micn  tlio  true  corneal  tissue  is  attacked  ulcer- 
ation occurs,  and  such  ulcers  may  be  extensive  and 
deeply  placed.  Iritis  may  be  a  complicating  cir- 
cumstance. Xot  infretiuently  the  corneal  ulcera- 
tion is  followed  by  perforation,  the  cornea  may 
become  entirely  oi^acjue  or  it  may  be  distorted  by 
staphylomatous  bulging.  Occasionally,  in  place  of 
an  acnixx'  ulceration,  the  ulce'rated  area  is  indolent 
in  character,  and  there  may  appear  just  at  the 
apex  of  the  pannus  a  shallow  central  ulcer  with 
a  slightly  turbid  base,  which  heals  and  leaves  a 
faintly  opaque  facet.  The  amount  of  vasculariza- 
tion in  i:)annus  varies  considerably.  Sometimes 
onl\  a  few  \essels  are  present  and  sometimes  the 
vessels  are  so  thickly  produced  that  the  appearance 
is  fleshy  in  character. 

Other  sequels  of  long-standing  trachoma  are 
trichiasis,  in  which  the  lashes  are  misplaced  and 
turn  inward  against  the  eyeball,  and  districhiasis, 
in  which  incurved  rows  of  suj^plementary  cilia  are 
(lc\  eloiDcd  from  the  intermarginal  part  of  the  lids. 
With  trichiasis  entropion,  or  an  inversion  of  the 
lid,  is  often  associated,  and  occasionally  the  oj^po- 
site  form  of  lid  misplacement  is  observed,  namely, 
ectropion.  These  deformities  of  the  lid  and  its 
border  arise  because  of  the  chronic  induration  and 
scar  tissue  which  always  ultimately  develop.  This 
tissue,  firmly  attached  to  the  tarsus,  which  itself 
is  softened  by  lymphoid  intilt ration,  contracts  and 


_; 


76  MILITARY   OPHTHALMIC  SURGERY 

bends  the  lid  and  its  border  from  their  normal  posi- 
tion. As  the  result  of  the  induration  of  the  mucous 
membrane  there  may  be  a  practical  obliteration 
of  the  conjunctival  sulcus,  the  membrane  under- 
going a  form  of  drying  up,  to  which  the  name 
xerosis  or  xerophthalmos  is  applied.  Patients  with 
advanced  trachoma,  especially  in  the  cicatricial 
stage,  often  have  a  curiously  sleepy  look.  They 
peer  uncertainly  through  their  narrow  palpebral 
fissures,  and  the  droop  of  the  lid  suggests  in  its 
appearance  a  partial  ptosis.  If,  as  is  the  case  in 
the  stage  of  increased  purulent  secretion,  the  pus 
glues  the  eyelids  together  the  discomforts  of  the 
subjects  of  this  disease  are  greatly  increased. 

Although  for  the  most  part  trachoma  is  confined 
to  the  conjunctiva  of  the  lids,  and  is  especially 
pronounced  in  the  retrotarsal  folds,  the  bulbar 
conjunctiva  does  not  always  escape  and  the  lesions 
of  the  disease  may  be  found  In  many  cases  in  the 
plica  and  the  caruncles,  a  situation  which  is 
of  diagnostic  import.  Furthermore,  in  many  of 
its  subjects  inflammation  of  the  lacrimal  sac  is 
present  (dacryocystitis)  and  trachomatous  changes 
may  be  detected  in  the  walls  of  this  sac  and  even 
in  the  mucous  membrane  of  the  nose.  Recently, 
Gifford  has  called  attention  to  the  frequency  with 
which  the  inner  end  of  the  canaliculus  is  occluded 
in  trachomatous  patients  in  whom  the  disease  is  of 
long  standing. 


TRACHOMA  77 

Cause. — The  cause  of  trachoma  is  unknown,  and 
while  there  is  no  proof  that  microorganisms  of  the 
bacterial  group,  or  blastomycetes,  are  etiological 
factors,  it  is  the  impression  of  Treacher  Collins 
that  the  disease  depends  upon  an  organism  of  ultra- 
microscopic  dimensions.  If  the  morbid  material 
from  a  trachomatous  conjunctiva  is  transferred 
to  another  eye  a  disease  like  the  one  from  which 
it  came  is  apt  to  originate,  and  in  this  sense  tra- 
choma is  specifically  communicable;  but  it  is  a 
contact  infection  and  cannot  be  transmitted  through 
the  air.  The  danger  of  the  spread  of  trachoma  is 
greatly  increased  if  there  is  such  morbid  secretion, 
and  therefore  it  is  that  where  the  hygienic  surround- 
ings are  unfavorable  and  where  the  inmates  of  insti- 
tutions, barracks,  armies,  camps,  etc.,  dwell  close 
together  and  are  uncleanly  and  careless  in  their 
personal  habits,  using  common  utensils,  handker- 
chiefs, bed-linen,  etc.,  the  facility  with  which  the 
disease  may  spread  is  greatly  increased. 

In  the  discharge  and  in  the  follicle  content  of 
fresh  untreated  trachoma,  less  easily  in  granulated 
lids  of  long  standing,  small  granules  resembling 
diplococci  were  discovered  by  Halberstadter  and 
Prowazek.  Surrounded  by  a  zone,  hence  called 
chhnnydozoa,  they  occur  either  isolated  or  grouped 
together  within  the  cell  next  to  the  nucleus.  These 
"cell  inclusions"  are  often  accompanied  by  small 
bodies  in  the  protoplasm  of  the  cells  and  outside 


J 


78  MILITARY   OPHTHALMIC   SURGERY 

of  the  cells,  which  are  called  Lindner's  ''initial 
bodies."  Because  the  Prowazek  bodies  are  com- 
paratively rarely  present  in  other  conjunctival  dis- 
ease their  detection  is  significant  even  though  their 
nature  is  unknown,  but  their  absence  does  not 
exclude  trachoma.  Also,  they  have  been  found  in 
some  types  of  ophthalmia  neonatorum  and  in  cer- 
tain forms  of  chronic  conjunctivitis,  and  it  is  said 


Fig.  9. — So-called  trachoma  bodies — epithelial    inclusions.      (Axenfeld.) 

in  their  early  stage  in  normal  conjunctivae.  When 
hrst  discovered  they  were  believed  to  be  the  cause 
of  trachoma,  but  later  this  belief  was  abandoned 
(Fig.  9). 

Pathological  Histology. — If  trachomatous  tis- 
sue is  examined  microscopically  the  following  cellular 
elements  will  be  found  in  the  follicles:  Lymphocytes, 
chiefly  in  the  peripheral  zone;  mononuclear  leuko- 


TRACHOMA  79 

cytes,  of  whicli  the  greater  portion  of  the  folHcles 
is  coniposcci ;  phagocytes  and  certain  accessory  ele- 
ments, for  instance,  multinuclear  cells.  Beneath 
these  follicles  dilated  lymph  vessels  are  conspicuous 
and  bloodvessels  may  extend  into  the  follicles. 
The  lymphadenoid  tissue  which  surrounds  the 
follicles  is  often  densely  infiltrated  with  leukocytes. 


^i- 


<■.- . 


/ 

^ 

•\ 

'  ^ 

V 

-•^^^^ 


Fig.  10. — Trachoma  of  the  retrotarsal  fold:  a,  follicle;  b,  difluse 
infiltration:  c,  Henlc's  gland  with  goblet  cells;  d,  lymph  vessel  filled  with 
leukocytes  (X  39).     (Holden.) 

This  scar  tissue  probably  depends  upon  a  prolifera- 
tion of  the  connective  tissue  of  the  conjunctiva 
(Fig.  10). 

Diagnosis. — When  trachoma  is  well  de\'cloped 
in  any  of  the  varieties  which  have  been  descril)ed 
there  is  comparatively  little  difificulty  in  making  a 
diagnosis,  and   if  microscopic  investigation  of  the 


J 


80  MILITARY   OPHTHALMIC  SURGERY 

tissue  Stained  with  the  Giemsa  material  should 
reveal  the  Prowazek  granules,  this  discovery  would 
be  a  factor  of  importance  in  any  case  of  doubt,  but 
it  would  not  be  pathognomonic.  In  point  of  fact, 
up  to  the  present  time  we  are  obliged  to  depend 
upon  clinical  signs  in  making  a  diagnosis. 

Usually  a  chronic  conjmiclivitis  or  a  chronic 
blennorrhea  with  enlargement  of  the  conjunctival 
papillae  can  be  readily  distinguished  from  trachoma 
by  the  greater  hypertrophy  in  the  latter  disease, 
and  particularly  by  the  thickening  and  induration 
of  the  tarsus. 

Venial  conjunctivitis  may  be  distinguished  from 
trachoma  by  the  flattened  appearance  of  the  granu- 
lations, often  covered  with  a  delicate  film,  as  if 
brushed  over  with  a  thin  layer  of  milk,  the  absence 
of  infiltration  and  of  pannus  and  by  the  history 
of  recurrences  at  special  seasons  of  the  year.  Also, 
eosinophilcs  are  conspicuously  present  in  the  secre- 
tion of  vernal  catarrh. 

Parinaud's  conjtmctivitis,  a  rare  disease,  has  some 
resemblance  to  certain  types  of  trachoma.  It  is 
associated  with  swelling  of  the  preauricular  glands, 
and  sometimes  of  the  lymph  glands  in  the  neck 
and  of  the  parotid  and  submaxillary  glands. 

Tuberculosis  of  the  conjunctiva,  also  an  infrequent 
disease,  should  be  distinguished  from  trachoma  by 
the  associated  swelling  of  the  lymph  glands,  and 
if  there  is  any  doubt,  by  submitting  the  tissue  to  a 


TRACHOMA  81 

microscopic  and  bacteriological  examination.  The 
tuberculin  test,  however,  would  not  be  satisfactory, 
as  in  a  good  many  instances  it  would  appear  that 
the  injection  of  tuberculin  has  been  followed  by 
a  reaction  in  what  would  seem  to  be  typically 
trachomatous  tissue. 

The  theory  that  all  follicles  in  the  conjuncti\'a 
represent  trachoma  has  often  been  maintained,  and 
therefore  the  well-known  Jolliciilosis  of  the  conjunc- 
tiva, sometimes  called  follicular  conjunctivitis,  and 
characterized  by  small  pinkish  prominences  in  the 
conjunctiva,  for  the  most  part  in  the  retrotarsal 
folds,  and  usually  arranged  in  parallel  rows,  has 
been  regarded  by  some  obserxers  as  a  form  of 
trachoma  and  called  follicular  trachoma. 

Now,  while  it  may  not  be  possible  in  the  early 
stages  of  trachoma  to  distinguish  the  so-called 
trachoma  bodies  from  large  lymphatic  follicles, 
there  is  a  distinct  difference  in  the  nature  of  the 
two  conditions.  In  the  folliculosis  referred  to  the 
foUicks  are  benign;  tlu'\-  are  smaller  by  more  than 
one-half  than  the  follicles  of  trachoma;  they  are  in 
large  measure  confined  to  the  fornices;  they  are 
never  seen  on  the  plica  or  the  bulbar  conjunctiva; 
pannus  is  not  associated  with  them;  and  finally 
they  disappear  without  leaving  any  scar  tissue. 
And  yet  between  these  benign  follicles  and  what 
Parsons  calls  the  serious  form  of  follicle  which 
belongs  to  trachoma,  border-line  cases  occur  which 


> 


82  MILITARY   OPHTHALMIC   SURGERY 

are  extremely  difficult  to  classify  and  of  which  no 
one  has  ever  yet  succeeded  in  writing  a  descrip- 
tion upon  which  a  satisfactory  diagnosis  could  be 
made.  Hence  the  importance  of  investigating 
carefully  during  the  inspection,  for  example,  of  sol- 
diers and  recruits,  every  case  of  reddened  conjunc- 
tiva, with  or  without  the  presence  of  follicles.  If 
the  follicles  are  irregularly  present,  and  not  dis- 
posed in  typical  parallel  rows,  and  especially  if 
they  are  deeply  set  and  beginning  induration  of 
the  tarsus  is  evident,  the  presence  of  trachoma 
becomes  more  than  a  suspicion.  Moreover,  even 
in  its  very  earliest  stages,  as  has  recently  been 
pointed  out  by  Stieren  and  Van  Kirk,  in  their 
search  for  trachoma  among  mill  workers,  loupe 
investigation  of  the  upper  portion  of  the  cornea 
will  not  infrequently  detect  a  very  delicate  ingrowth 
of  vessels,  the  first  beginnings  of  a  pannus,  not 
discoverable  by  naked-eye  examination.  This  sign 
is  an  important  one,  and  is  not  present  if  the 
follicles  are  benign. 

While  it  is  well-nigh  axiomatic  to  state  that  any 
granular  disease  of  the  conjunctiva  which  results 
in  cicatrization  is  trachoma,  there  are  a  few  other 
affections  of  the  conjunctiva  which  give  rise  to 
scar  tissue,  notably  pemphigus.  But  in  this  dis- 
ease, a  very  rare  one,  ulcers  covered  with  mem- 
branes are  evident,  which  precede  the  cicatrizing 
process,  and  the  lesions  of  pemphigus  elsewhere  on 


TRACHOMA  83 

the  1)()(1\  are  discoN'cred  !)>■  the  historv'  or  by  actual 
()l)ser\ation  and  ser\'c  to  establish  the  diagnosis. 
The  scars  following  burns  of  the  conjunctiva  are 
totalK'  unlike  those  of  trachoma,  and  the  history 
is  axailable,  and  the  same  is  true  of  moderate 
cicatrization  of  the  conjunctiva  which  is  occasion- 
all\'  seen  after  purulent  conjunctivitis,  and  more 
freiiuenil)  in  connection  with  chronic  blepharitis 
and  its  accompanying  ectropion.  The  pannus  of 
phlyctenular  disease  is  usually  unevenly  or  irregu- 
larly distributed,  and  is  not  largely  confined,  as  in 
I  he  majority  of  cases  of  trachoma,  to  the  upper 
half  of  the  cornea.  (See  also  p.  74.)  Also,  the 
historN  of  the  two  affections  is  totally  different, 
and  this  applies  to  the  pannus  which  sometimes 
follows  trichiasis  produced  by  conditions  other  than 
granular  lids,  for  example,  burns. 

Trachoma  is  often  spoken  of  as  a  disease  of  adult 
life.  This  is  a  mistake;  severe  cases  are  found  in 
\ery  young  children,  and  this  has  been  especially 
triir  in  tlu'  iincstigations  of  IMcMullen,  Stucky, 
White  and  other  surgeons,  who  hax'e  had  large 
opportunities  of  observing  trachoma,  as  it  occurs 
in  the  western  portion  of  our  own  country,  and 
especially  in  the  Appalachian  region. 

Treatment. — The  treatment  of  trachoma  natu- 
rally divides  itself  into  medicamenlal,  mechanical, 
chemical  and  operative  procedures. 

As   medicamental    measures    to   check    infccti\'e 


84  MILITARY   OPHTHALMIC   SURGERY 

secretion,  the  usual  antiseptic  and  slightly  astrin- 
gent lotions  may  be  employed.  Those  which  serve 
the  best  purpose  are  saturated  solutions  of  boric 
acid,  equal  parts  of  boric  acid  and  physiological  salt 
solution,  bichloride  of  mercury  (i  to  5000,  i  to 
10,000)  and  cyanide  of  mercury  (i  to  1500).  The 
irrigations  should  be  liberal,  preferably  with  warmed 
solutions,  and  frequently  repeated.  To  control  the 
purulent  quality  of  the  secretion  a  solution  of  nitrate 
of  silver  (2  per  cent.),  painted  over  the  diseased 
conjunctiva  after  thorough  eversion  of  the  lid,  and 
neutralized  after  the  white  film  forms  by  irrigations 
with  physiological  salt  solution,  is  strongly  indicated. 
For  the  same  purpose  argyrol  (25  per  cent.)  and 
protargol  (10  per  cent.)  are  much  employed.  None 
of  the  silver  preparations  should  be  used  for  long 
periods  of  time  lest  argyrosis  of  the  conjunctiva  be 
produced,  and  on  this  account  these  preparations, 
especially  argyrol  and  protargol,  silvol  and  the  like 
should  not  be  given  to  the  patient  for  home  use. 
Recently  a  0.5  per  cent,  oily  solution  of  dichlor- 
amin-T  has  been  recommended  in  the  treatment  of 
trachoma  and  has  been  reported  as  a  useful  agent 
to  control  abnormal  secretion.  It  does  not  seem  to 
the  author  to  have  advantages  in  this  regard  over 
other  remedies,  but  it  is  only  right  that  it  should 
have  a  full  trial  before  deciding  as  to  its  value  in 
this  disease. 

Abnormal  secretion  being  in  control,  and    espe- 


TRACHOMA  85 

cially  when  eruptions  of  new  granulations  are  asso- 
ciated with  beginning  cicatricial  changes,  sulphate 
of  copper,  abandoned  by  some  practitioners,  is  in 
the  judgment  of  the  author  an  admirable  remedy. 
A  smooth  crystal  of  sulphate  of  copper  is  applied 
to  all  portions  of  the  affected  palpebral  conjunctiva, 
and  the  surface  after  a  few  minutes  flushed  with 
cold  sterile  water.  An  excellent  application,  which 
may  substitute  the  copper  stick,  is  a  5  per  cent, 
solution  of  this  remedy  in  glycerin,  applied  with  a 
cotton  mop,  the  patient  several  times  a  day  instill- 
ing into  the  conjunctival  cul-de-sac  a  i  per  cent, 
solution  of  the  same  preparation.  To  hasten  the 
absorption  of  the  follicles  and  to  prevent  xerosis 
of  the  conjunctiva,  applications  of  boroglyceride 
(30  to  50  per  cent.)  arc  useful,  as  is  also  tannin  and 
glycerin,  30  to  60  grains  to  the  ounce  (1.95  to  3.9 
grams  to  30  c.c).  During  acute  exacerbations  of 
trachoma,  so-called  acute  trachoma,  in  addition  to 
the  usual  collyria,  if  there  is  iritic  involvement, 
mydriasis  is  indicated.  This  may  be  secured  with 
atropin  sulphate,  4  grains  (0.26  gram)  to  the  ounce 
(30  c.c),  or  preferably  with  scopolamin  hydro- 
bromate,  2  grains  (0.13  gram)  to  the  ounce  (30  c.c.) 
of  distilled  water. ^  A  corneal  ulcer,  if  infected, 
should    be   cauterized    with    trichloracetic  acid   or 


'  0(  the  many  astringent  and  antiseptic  applications  which  have  been 
tried  and  recommended,  only  those  which  the  author  has  found  useful 
are  mentioned. 


J 


I 

L 


86  MILITARY   OPHTHALMIC  SURGERY 

carbolic  acid,  and  in  these  circumstances  holocain 
(2  per  cent.)  and  dionin  (5  per  cent.)  are  of  value. 
AIechanical  MEASURES.^From  the  very  ear- 
liest days  trachoma  therapeusis  has  included  mas- 
sage, scraping  and  scratching.  Massage  associated 
with  medicaments  is  more  efficacious  than  simple 
massage,  for  example,  by  introducing  a  small 
massage  glass  ball  beneath  the  lid  and  making 
counter-pressure  on  the  cutaneous  palpebral  sur- 
face. As  the  result  of  long  experience  the  late  Dr. 
Charles  H.  Beard  highly  recommended  the  follow- 
ing procedure:  After  instilling  one  drop  of  adrenalin 
solution  (i  to  2000),  a  tightly  wound  cotton  mop, 
dipped  in  a  solution  of  bichloride  of  mercury  (i  to 
250)  is  after  eversion  of  the  lid  rubbed  firmly  over 
the  affected  conjunctiva  for  two  minutes,  the  cot- 
ton being  kept  moist  with  renewed  applications  of 
the  sublimate  solution.  Next,  the  conjunctival 
surface  is  thoroughly  irrigated  with  a  hot  boric 
acid  solution,  followed  by  a  drop  of  a  4  per  cent, 
solution  of  cocain.  This  procedure  should  be 
repeated  at  two-day  intervals,  and  on  the  alternate 
days  the  same  type  of  massage  is  employed,  save 
only  that  for  the  bichloride  solution  argyrol  (50  per 
cent.)  is  substituted.  The  author  has  found  this 
procedure  of  value,  using  the  bichloride  in  the 
strength  of  i  to  300  or  i  to  500,  especially  during 
the  stage  of  lymphoid  infiltration  and  decided 
follicular  eruption,  unassociated  with  much  abnor- 


TRACHOMA  87 

null  discharge.  In  place  of  the  bichloride  mixture 
a  solution  of  cyanide  of  mercury  (i  to  500)  may  be 
used. 

A  more  xigorous  procedure  than  massage  is  the 
operation  called  brassage  or  grattage,  which  is  per- 
formed as  follows: 

After  the  patient  is  anesthetized  the  conjunctival  sur- 
face is  exposed  in  the  manner  already  described.  The 
trachomatous  tissue  is  then  deeply  scarified,  the  inci- 
sions running  parallel  to  the  margin  of  the  lid.  The 
surface  is  next  rubbed  with  the  back  of  the  scalpel  and 
the  conjuncti\a  vigoroush'  scrubbed  with  an  ordinary 
tooth-brush  carrying  a  solution  of  bichloride  of  mer- 
cury, 1  to  2000.  If  the  palpebral  fissure  is  very  narrow, 
canthotomy  should  precede  the  operation.  The  after- 
treatment  consists  in  measures  to  prevent  adhesions 
between  the  folds  of  the  conjuncti\a  and  the  conjuncti\al 
cul-de-sac  and  the  daily  application  of  a  sublimate  solu- 
tion of  the  same  strength  as  that  originally  used  for  at 
least  a  week  following  grattage.  The  subsequent  treat- 
ment comprises  the  usual  antiseptic  lotions  and  applica- 
tions until  cure  is  effected. 

D.  H.  Coover  recommends  that  grattage  be  per- 
formed with  strips  of  sterilized  sandpaper,  and  D. 
W.  White  has  designed  an  instrimient  for  the  pur- 
l)ose,  called  silica  trachoma  rasps,  made  by  fixing 
sand  on  orange-wood  sticks.  With  brossage,  how- 
ever accomplished,  the  author  has  had  little  experi- 
ence. As  the  late  Dr.  Beard  remarked,  it  is  not 
an  extremely  bad  measure,  but  it  is  far  from  being 


88  MILITARY   OPHTHALMIC  SURGERY 

as  good  as  some  others,  and  it  has  never   appealed 
to  the  author. 

A  description  of  the  operative  procedure  used 
by  the  PubHc  Health  Service  has  kindly  been 
furnished  by  Surgeon  John  McMullen,  and  is  as 
follows : 

The  eyelid  is  everted  by  means  of  a  special 
forceps.  Next  by  the  use  of  two  scalpels,  one  in 
either  hand,  the  conjunctiva  is  gradually  raised 
and  the  full  extent  of  the  cul-de-sac  is  exposed  and 
the  granulations  are  scarified  superficially,  begin- 
ning from  the  bottom  and  extending  forward 
toward  the  ciliary  margin.  Succeeding  this,  in 
some  cases,  it  is  well  to  use  a  moderately  stiff  brush 
with  bichloride  solution  i  to  2000.  The  next  step 
is  to  use  fine  mesh  gauze  sponges,  and  these  are 
rubbed  over  the  entire  afi'ected  conjunctiva  until 
the  surface  is  smooth  and  the  hypertrophy  and 
granulations  have  been  removed.  This  can  be 
determined  by  the  reappearance  of  the  small 
bloodvessels  to  view.  The  operation  is  completed 
by  again  everting  the  eyelid  and  thoroughly  wash- 
ing out  of  the  conjunctiva  all  blood-clots,  etc.,  with 
a  boric  acid  solution,  followed  by  the  instillation 
of  two  drops  of  a  20  per  cent,  solution  of  argyrol. 
The  after-treatment  consists  in  cleansing  the  eyes, 
every  three  hours,  with  a  boric  solution  and  the 
instillation  of  a  20  per  cent,  argyrol  solution.  This 
is  continued  for  several  days  or  until  all  sloughs 
have  disappeared. 


TRACHOMA  89 

The  amount  of  traumatism  necessary  depends 
entirely  on  the  individual  case  in  hand,  and  the 
operator  is  guided  solely  by  the  necessity  of  each 
case.  If  a  radical  operation  has  been  performed 
the  eyes  should  be  examined  carefully  for  the  next 
twenty-four  to  forty-eight  hours  for  adhesions,  and 
these  should  be  broken  up  immediately.  At  the 
end  of  about  one  week  following  operation,  if 
granulations  or  rough  surfaces  are  found,  these 
should  be  lightly  touched  with  a  2  per  cent,  solution 
of  silver  nitrate,  repeated  two,  three,  four  or  more 
times  a  week. 

Expression. — This  procedure  is  usually  performed 
according  to  the  method  of  the  late  Dr.  H.  Knapp, 
and  often  known  as  Knapp's  operation : 

After  the  patient  is  etherized,  or  a  submucous  injec- 
tion of  cocain  is  made,  the  upper  lid  is  everted,  seized 
at  the  convex  border  of  the  tarsus  with  a  pair  of  fixation 
forceps,  and  drawn  away  from  the  eye  so  as  to  expose 
thoroughly  the  whole  palpebrobulbar  conjunctiva.  If 
the  tissue  is  infiltrated  it  may  be  superficially  scarified, 
preferably  with  a  three-bladed  scarifier.  One  blade  of 
the  roller  forceps  is  pushed  deeply  between  the  ocular 
and  palpebral  conjunctiva  and  the  other  is  applied  to 
the  e\erted  surface  of  the  tarsus.  The  forceps  is  com- 
pressed with  some  force,  drawn  forward,  and  the  infil- 
trated soft  substance  squeezed  out  as  the  cylinders  roll 
over  the  surfaces  of  the  fold  held  between  it.  This 
maneuver  is  repeated  until  all  the  morbid  material  has 
been  expressed — in  other  words,  to  use  Knapp's  expres- 
sion, until  the  conjunctiva  has  been  thoroughly  milked. 


90 


MILITARY   OPHTHALMIC  SURGERY 


The  lower  lid  is  treated  in  the  same  way.  During  the 
operation  the  surfaces  should  be  frequently  flooded  with 
a  tepid  solution  of  bichloride  of  mercury,  1  to  8000, 
and  after  the  operation  cold  compresses  may  be  laid  on 
the  lid  for  twenty-four  hours.  The  following  day  the 
lids  should  be  everted,  and  usually  a  delicate  grayish 


Fig.   II. — Knapp's  operation  for  trachoma.      (Hansell  and  Sweet.) 

layer  of  lymph  will  be  found  covering  the  entire  area  of 
operation.  This  should  be  removed,  the  swollen  mucous 
membrane  exposed  and  touched  in  the  ordinary  way 
with  a  solution  of  nitrate  of  silver,  5  to  10  grains  (0.324 
to  0.65  gram)  to  the  ounce  (30  c.c).  Each  day  this 
treatment   should   be   repeated   until    the   swelling   has 


TRACHOMA  01 

subsided,  when  the  daily  application  of  a  crystal  of  sul- 
phate of  copper  is  advisable  (Fig.  11), 

This  operation  the  author  has  employed  exten- 
si\c'h'  and  always  in  suitable  cases  with  satisfac- 
tion. It  is  especially  valuable  in  cases  of  spawn- 
like granulations  (follicular  trachoma)  and  diffuse 
hyalin  infiltration,  and  may  be  used  in  cicatricial 
trachoma  associated  with  patches  of  hyaline  degen- 
eration. It  is  contra-indicated  during  an  acute 
process,  or  if  there  is  much  purulent  discharge. 
According  to  Weeks  its  effectiveness  is  increased 
if  after  the  expression  a  germicide,  e.  g.,  bichloride 
of  mercury  (i  to  2000),  is  brushed  into  the  tissues. 

In  place  of  the  Knapp  roller  forceps  the  Noyes 
or  Prince  forceps  may  be  used,  or  the  expressor  of 
Kuhnt,  made  of  two  coapting  perforated  metal 
plates,  which  has  the  advantage  that  it  causes  less 
traction  on   conjunctiv^al   membrane. 

The  expression  operation  has  been  radically 
modified  by  D.  \V.  \\'hite  and  P.  C.  White,  in  that 
they  expose  the  tarsus  of  the  upper  lid  by  dissect- 
ing back  its  conjunctival  covering  and  making  a 
number  of  vertical  incisions  in  the  tarsus.  Each 
vertical  strip  being  rolled  in  the  manner  described, 
and  the  roller  may  also  include  the  affected  con- 
junctiva, this  membrane  afterward  being  sutured 
again  into  place.  This  modified  roller  or  expression 
operation  has  the  evident  advantage  of  getting  rid 
of  tarsal  lymphoid  infiltration,  which  is  not  so  well 


J 


i 


92  MILITARY  OPHTHALMIC  SURGERY 

or  not  at  all  accomplished  in  the  simpler  procedure. 
The  author  has  had  no  experience  with  this  method, 
which,  next  to  certain  radical  measures  presently 
to  be  described,  its  designer  considers  to  be  the  most 
satisfactory  procedure. 

Chemical  Measures. — This  term  has  been  applied 
to  those  procedures  which  include  cauterization 
with  various  caustics  and  with  the  actual  or  thermic 
cautery,  and  may  also  include  scarification  of  the 
conjunctiva,  followed  by  electrolysis.  None  of 
these  procedures  possesses  any  real  advantage,  and 
severe  cauterization  is  definitely  contra-indicated. 
The  x-ray  treatment  of  trachoma,  as  well  as  its 
treatment  by  radium,  bid  fair  for  a  short  time  to 
supply  a  new  therapeutic  measure  in  the  treatment 
of  this  intractable  disease.  The  author's  own 
experience  with  the  x-rays,  while  a  limited  one, 
yielded  results  which  were  indifferent,  and  May's 
observ^ations  indicate  that  the  effect  of  radium  is 
not  as  favorable  as  that  of  sulphate  of  copper. 
Carbon  dioxide  snow  has  been  employed,  and 
recently  Tyrrell,  in  England,  has  maintained  that 
this  agent  represents  one  of  the  most  successful 
methods  of  treating  trachoma  when  the  follicles 
are  over  the  tarsus.  The  author's  experience  with 
carbon  dioxide  is  too  limited  to  enable  him  to 
express  an  opinion  as  to  its  effectiveness. 

Operative  Measures. — In  addition  to  the  opera- 
tion of  expression  already  described  in  connection 
with    the    mechanical    procedures,    it    remains    to 


TRACHOMA  93 

briefly  describe  curettage;  excision  of  the  retro  tarsal 
fold,  or  of  a  strip  of  the  infiltrated  fornix;  removal 
of  a  part  of  the  tarsus  at  the  same  time  that  the 
strip  of  infiltrated  fornix  is  excised  (the  so-called 
combined  excision) ;  and  extirpation  of  the  tarsus 
(Kuhnt's  extirpation). 

1.  Curettage. — This  procedure  has  a  very  limited 
application,  although  it  at  one  time  was  much 
practised.  It  consists  essentially  in  excising  indi- 
vidual follicles  and  removing  their  contents  with 
a  small  curette,  a  tedious  procedure,  which  is  utterly 
unsuitable  should  there  be  extensive  infiltration,  and 
if  i)ractised  at  all,  is  applicable  only  to  those  condi- 
tions in  which  small  islands  of  follicles  exist,  or 
ha\-e  escaped  some  of  the  other  procedures  which 
have  been  described. 

2.  Simple  Excision. — Following  a  suggestion  of  Romer, 
a  subjunctival  injection  of  cocain  (4  per  cent.)  causes 
the  diseased  transition  fold  of  the  conjunctiva  to  bulge 
forward,  and  makes  plain  a  line  of  demarcation  between 
the  diseased  area  and  the  healthy  bulbar  conjunctiva. 
The  convex  margin  of  the  tarsus  is  brought  within  the 
grasp  of  two  pairs  of  forceps,  and  an  incision  is  made 
in  the  healthy  scleral  conjunctiva  close  to  the  line  of 
demarcation  from  the  outer  to  the  inner  canthus. 
Miiller's  muscle,  which  has  a  l)luish  look,  is  usually 
recognized  when  the  wound  separates  and  the  bulbar 
conjunctixa  retracts.  Next,  three  sutures  are  intro- 
duced through  the  margin  of  the  bulbar  conjunctiva, 
which  is  undermined.  The  next  incision  is  so  placed  as 
to  separate  the  transitional  fold  from  the  tarsus;  the  dis- 
eased   tissue   King   between    these   two   incisions,    being 


> 


94  MILITARY  OPHTHALMIC  SURGERY 

seized  at  the  inner  canthus,  is  separated  from  the  under- 
lying tissue  with  blunt  scissors  and  removed.  Finally, 
the  needles  attached  to  the  sutures  already  in  place  are 
placed  through  the  edge  of  the  tarsus  and  tied. 

This  operation  is  of  some  service  if  the  trachoma- 
tous process  is  largely  confined  to  the  transition 
folds,  and  there  are  no  indications  of  serious  lym- 
phoid infiltration  of  the  tarsus  itself.  It  is  some- 
times quite  effective  in  checking  a  developing 
pannus,  and  is  nearly  always,  if  the  indication  as 
given  is  strictly  attended  to,  followed  by  improve- 
ment. Should  the  lower  fornix  be  selected  for  this 
type  of  incision,  and  Kuhnt  is  accustomed  in  large 
measure  to  restrict  it  to  this  area,  the  upper  lid  is 
held  back  and  the  patient  is  required  to  look 
upward.  Next,  the  surgeon  everts  the  lower  lid 
and  excises  the  required  strip  of  conjunctiva,  begin- 
ning usually  upon  the  outer  side.  In  these  lower 
fornix  excisions  sutures  are  rarely  necessary.  In 
both  instances  the  operation  should  be  followed  by 
free  irrigation,  the  operated  area  dusted  over  with 
finely  powdered  iodoform,  and  the  lids  bandaged. 
This  bandage  may  be  removed  at  the  end  of  a 
couple  of  days,  and  the  usual  antiseptic  irrigations 
employed. 

3.  Combined  Excision. — This  operation  is  a  muco- 
tarsal  excision  whereby  the  affected  transitional 
folds  and  the  infiltrated  part  of  the  tarsus  are 
removed.     It  may  be  performed  as  follows: 


77\MC7/O.U.l 


After  free  eoeainizatioii  of  the  eonjiinctix'a,  the  eye 
l)eing  rotated  downward,  the  upper  Hd  is  doubly  everted 
and  held  in  position  by  means  of  two  fixation  forceps, 


Fig.  12.— Combined  excision.     First  stage.     (Wuotton,  Arch   of 
Ophthal.) 


in  such  a  manner  that  the  bulbar  cT)njunctiva  is  drawn 
upward  upon  the  surface  of  the  tarsus.  The  first  inci- 
sion, which  should  penetrate  the  conjunctiva  alone,  is 
made  transversely  at  the  juncture  of  the  palpebral  and 


r 


96  MILITARY   OPHTHALMIC  SURGERY 

bulbar  conjunctiva   (Fig.   12),   thus   separating   the  dis- 
eased and  healthy  tissue.     Injury  of  Miiller's    muscle, 


Fig.  13. — Combined  excision.     Second  stage. 

Ophthal.) 


(Wootton,  Arch,  of  Tlie 

In  01 


which    lies    directly    beneath,    must    be    avoided.     The 
retracted  bulbar  conjunctiva  is  next  separated  from  the  jdliji, 
subjacent  tissue  for  a  distance  of  4  mm.    Three  sutures 


TRACHOMA  97 

armed  with  a  needle  at  each  end  are  inserted  through 
the  lower  lid  of  the  w^ound.  I'^ollowing  this  dissection 
the  lid  is  allowxxl  to  take  the  position  of  single  eversion, 
and  a  horn  or  Jaeger  plate  is  placed  beneath  the  skin 
surface  of  the  eyelid,  the  margin  of  which  is  pressed 
firmly  u})on  it  (Fig.  13).  Next  an  incision  is  made  for 
the  entire  length  of  the  lid  2.5  mm.  from  its  inner  mar- 
gin and  exactly  parallel  to  it.  The  lateral  horns  of  the 
two  incisions  are  joined  by  a  short  vertical  cut  at  their 
external  and  internal  extremities.  Thus  the  boundaries 
Di  the  diseased  conjunctiva  and  tarsus  are  fixed.  The 
next  step  consists  in  dissecting  up  this  area,  care  being 
taken  not  to  injure  the  orbicularis  or  M tiller's  muscle. 
How  much  of  the  diseased  tarsus  shall  be  removed 
lepends  upon  the  severity  of  the  condition  and  the  dis- 
tribution of  the  lesions;  usually  the  piece  removed  is 
about  2.5  cm.  long  and  1  cm.  broad.  Hemorrhage  hav- 
ing been  checked,  the  operation  is  completed  by  stitch- 
ing the  margin  of  the  bulbar  conjunctiva  to  the  rim  of 
tarsus  which  remains,  and  it  is  important  that  the 
:onjunctiva  shall  be  united  exactly  to  corresponding 
points  of  the  tarsal  cartilage.  The  eye  is  closed,  and  the 
surgeon  makes  gentle  traction  on  the  middle  suture  in 
1  direction  vertical  to  the  lid  margin.  The  point  where 
Lhe  suture  crosses  the  upper  margin  of  the  tarsal  rim 
is  grasped  with  toothed  forceps,  one  blade  being  passed 
aeneath  the  lid,  which  is  then  everted.  The  suture  is 
next  passed  through  the  upper  margin  of  the  tarsal  car- 
tilage at  the  point  designated  by  the  teeth  of  the  forceps, 
rhe  other  sutures  are  treated  in  like  manner  (Fig.  14). 
(n  order  to  avoid  pressure  on  the  cornea  the  sutures 
nay  be  placed  thus,  following  the  method  of  von 
31acowicz:  The  sutures  are  armed  with  two  needles, 
yhich  are  passed  entirely  through  the  lid,  the  anterior 
7 


98  MILITARY   OPHTHALMIC  SURGERY 

one  transfixing  the  upper  margin  of  the  cartilage,   the 
posterior  one  the  aponeurosis  muscle  and  skin  in  close 


Fig.  14. — Placing  of  sutures.     (Wootton,  Arch,  of  Ophthal.) 

proximity.     The  sutures  are  tied  over  a  roll  of  gauze, 
and  may  be  removed  on  the  fifth  day.^  j 

1  Many  modifications  of  this  operd,tion  have  been  described.  The  ' 
one  recorded  here  is  condensed  and  somewhat  modified  from  H.  W. 
Wootton's  description  (Archives  of  Ophthahnology,  vol.  xxxix).  D. 
W.  White  and  P.  C.  White  have  evolved  an  elaborate  technic,  fully 
described  (Ophthalmology',  October,  1015),  and  are  enthusiastic  advo- 
cates of  the  removal  of  the  tarsal  cartilage  and  palpebral  conjunctiva 
in  the  treatment  of  chronic  trachoma. 


TRACHOMA  99 

This  operation,  originally  designed  by  Heisrath, 
and  modified  and  improved  by  Kuhnt  and  other 
surgeons  is  suited  to  chronic  trachoma  with  tarsal 
infiltration,  to  chronic  trachoma  with  pannus  inde- 
pendently of  the  tarsal  condition,  and  in  the  so- 
called  gelatinous  trachoma  of  retro  tarsal  folds  and 
with  thickening  of  the  tarsus. 

Excision  of  the  Tarsus. — This  operation  is  recom- 
mended by  Kuhnt  in  some  cases  of  chronic  tra- 
choma with  great  thickening  of  the  tarsus  in  the 
cicatricial  stage.  The  structure  is  exposed  through 
an  incision  running  the  whole  length  of  the  tarsal 
cartilage,  22  mm.  from  the  free  border.  After 
exposure  the  tarsus  is  dissected  from  its  position 
and  detached  from  the  levator  tendon. 

Treatment  op^  Pannus. — Ordinarily  pannus  sub- 
sides when  the  various  measures  which  have  been 
described  succeed  in  dissipating  the  granulated  sur- 
face of  the  palpebral  conjunctiva.  Formerly  invet- 
erate pannus  was  often  treated  by  means  of  the 
de  W'ecker  jeqiiirity  method,  to  wit,  producing  a 
violent  conjunctivitis  with  a  3  per  cent,  solution 
of  this  drug — a  technic  which  has  been  abandoned. 
Jequiritol  and  jequiritol  serum,  introduced  by 
Romer,  have  also  ceased  to  claim  attention. 

Not  infrequently  stubborn  pannus  is  materially 
benefited  by  peritomy,  or  more  properly,  peridcc- 
toniy,  which  consists  in  excising  a  strip  of  the  bul- 
bar conjunctiva  about  3  mm.  in  width,  surrounding 


100  MILITARY   OPHTHALMIC  SURGERY 

the  cornea,  followed  by  scarification  of  the  vessels 
at  the  Hmbus.  In  certain  cases  of  advanced  and 
old  pannus  remarkable  results  follow  the  dissec- 
tion from  the  cornea  of  the  opaque  and  vascular 
tissue.  It  has  to  be  done  with  skill  and  care  lest 
the  cornea  be  perforated,  and  is  a  method  of  pro- 
cedure recommended  by  the  late  Dr.  Gruening 
many  years  ago.  Should  there  be  intense  blepharo- 
spasm, and  on  this  account  dangerous  compression 
of  the  cornea,  or  should  the  palpebral  fissure  be 
greatly  contracted,  the  operation  of  canthoplasty 
is  indicated.     It  is  performed  as  follows: 

One  blade  of  a  pair  of  probe-pointed  scissors  is  intro- 
duced behind  the  external  commissure,  and  the  entire 
thickness  of  the  tissues  is  divided,  making  the  wound 
in  the  skin  a  little  longer  than  that  in  the  conjunctiva. 
The  wound  margins  are  next  separated,  and  the  surgeon 
loosens  the  conjunctiva  at  the  apex  of  the  incision  and 
frees  it  from  the  underlying  tissue.  Three  sutures  are 
passed,  one  uniting  the  extremity  of  the  conjunctival 
flap  to  the  center  of  the  skin  incision,  and  one  suture 
above  and  one  below,  near  the  angles  of  the  wound 
(Fig.  15).  Division  of  the  external  canthus  without  sub- 
sequent introduction  of  sutures  is  known  as  cantJwtomy. 

If  stenosis  of  the  lachrymonasal  duct  is  present, 
it  must  be  rendered  patulous,  and  chronic  dacryo- 
cystitis treated  by  excision  of  the  lachrymal  sac. 

Prognosis. — Always  a  tedious  disease  and  sub- 
ject to  relapses  and  exacerbations,  trachoma  is 
curable  if  properly  managed,  and  the  improvement 


TRACHOMA  101 

in  prognosis  has  been  evident  since  carefully  applied 
mechanical  measures  and  well-considered  operative 
procedures  have  given  place  to,  or  been  associated 
with,  medicamental  applications.  This  is  no.tably 
true  in  the  work  of  Dr.  John  McMullen,  Dr. 
Siuck\-  and    many    others    in    Kentucky    and    the 


Fig.  15. — Canthoplasty.     The  stitches  ready  to  be  tied.      (Haab.) 


neighboring  regions,  and  of  the  Drs.  White  and 
others  in  further  Western  States.  The  impor- 
tance of  the  early  detection  of  trachoma  before 
decided  corneal  complications  and  pronounced  lid 
disturbance  ha\-e  arisen  cannot  be  too  strongly 
emphasized. 


102  MILITARY  OPHTHALMIC  SURGERY 

Prophylaxis. — In  camps,  cantonments  and  bar- 
racks there  should  be  systematic  and  repeated 
inspection  of  the  soldiers'  eyes  after  thorough  ever- 
sion  of  the  lids,  and  all  suspects  promptly  isolated 
and  kept  from  mingling  with  their  fellows  until  the 
conjunctivse  are  entirely  restored  to  a  normal  con- 
dition. It  is  well  known  that  trachoma  is  often 
carried  into  armies  from  the  outside;  thus  in 
trouble  in  this  regard  in  the  Allied  Armies  abroad 
it  was  largely  through  alien  laborers  that  the  infec- 
tion was  introduced.  It  is  of  paramount  impor- 
tance that  the  eyes  of  all  recruits  should  be  inspected 
before  they  are  assigned  to  duty  in  the  various 
camps  and  cantonments.  This  is  particularly  true 
where  in  our  National  Army  recruits  and  drafted 
men  come  from  those  regions  in  which  the  preva- 
lence of  trachoma  among  the  civil  population  is 
conspicuous  (p.  64).  The  ease  with  which  the 
infection  can  spread,  especially  if  in  the  eyes  of 
the  carriers  purulent  secretion  is  present,  is  well 
known,  and  the  careless  use  of  towels,  linen,  hand- 
kerchiefs and  common  utensils  cannot  be  too 
strongly  condemned.  Civilian  visitors  and  work- 
men coming  from  areas  where  trachoma  is  known 
to  exist  should  not  escape  inspection,  and  if  any  of 
them  have  eyes  which  are  not  above  suspicion,  he 
or  she  should  be  forbidden  to  enter  the  military 
zone. 


ACUTE   CONJUNCTIVITIS  103 

ACUTE  CONJUNCTIVITIS. 

A  mild  variety  of  this  affection,  l^nown  usually 
as  simple  catarrhal  conjunctivitis,  in  which  only  a 
moderate  amount  of  mucopurulent  secretion,  con- 
taining generally  only  the  ordinary  pus-producing 
organisms,  gathers,  and  which  is  contagious  but 
not  actively  so,  is  readily  managed.  The  eyes 
should  be  frequently  irrigated  with  a  saturated 
boric  acid  solution  and  the  conjunctiva  of  the 
c\crted  lid  brushed  with  a  i  per  cent,  solution  of 
nitrate  of  silver,  or  a  25  per  cent,  solution  of 
argyrol  should  be  dropped  into  the  conjunctival 
sac  se\eral  times  a  day.  This  sufifices  to  dissipate 
the  afTection  in  a  few  days. 

A  more  active  manifestation  of  this  disease, 
which  on  account  of  certain  characteristic  features 
may  be  regarded  as  a  distinct  affection,  is  acute 
contagious  conjunctivitis,  commonly  known  as  "pink 
eye."  In  addition  to  marked  edema  of  the  lids, 
very  free  purulent  secretion,  often  gathered  into 
long  strings,  and  subconjunctival  hemorrhages  are 
evident.  In  typical  cases  the  affection  is  caused 
by  the  Koch-Weeks  bacillus;  but  an  almost  exactly 
similar  condition  is  due  to  the  pneumococcus. 
Intensely  contagious,  this  infection  spreads  rap- 
idly from  one  person  to  another,  and  where  indi- 
\  i(Iuals  are  closely  associated,  as  in  schools,  camps, 
etc.,  can  speedily  develop  into  an  epidemic.  The 
duration  of  the  disease  is  usually  from  sLx  to  ten 


104  MILITARY   OPHTHALMIC  SURGERY 

days.     The  prognosis  is  entirely    favorable.     (See 
Plate  VIII.) 

The  treatment  does  not  differ  from  that  already 
detailed,  except  that  it  should  be  more  vigorous. 
In  addition  to  the  usual  collyria,  bichloride  of 
mercury  may  be  tried,  i  to  lo,ooo.  A  mixture  of 
sulphate  of  zinc,  i  grain  (0.13  gram)  to  the  ounce  of 
sterile  water  (30  c.c),  is  valuable;  iced  compresses 
afford  relief  at  the  height  of  the  affection.  Argyrol 
is  commonly  prescribed,  but  it  should  not  be  too 
long  continued.  Brushing  the  everted  lids  with  a 
I  per  cent,  solution  of  nitrate  of  silver  is  useful, 
the  excess  to  be  neutralized  with  physiological  salt 
solution. 

GONORRHEAL  CONJUNCTIVITIS  OF  ADULTS. 

This  can  usually  be  traced  to  its  source  of  con- 
tagion from  an  acute  gonorrhea  or  a  gleet,  by 
contact  with  soiled  fingers  or  linen  or  from  an  eye 
affected  with  this  type  of  conjunctivitis,  and  like 
urethral  gonorrhea  is  due  to  the  activities  of  the 
gonococcus,  which  is  readily  detected  in  the  pus 
after  staining  smears  with  the  ordinary  reagents,  for 
example,  methylene  blue.  (See  Plate  \'1 1 1.)  Usually 
appearing  within  twenty-four  to  forty-eight  hours 
after  inoculation,  its  symptoms  develop  with  great 
activity;  rapid  and  tense  edema  of  the  lids;  thick, 
greenish-yellow  pus;  chemosis  of  the  bulbar  conjunc- 
tiva, and  unless  the  violence  of  the  inflammation  is 
quickly  subdued,  haziness  of  the  cornea;  ulceration 


PLATE    VIII 


.-«a 


fra.F 


Fia.m 


Fig.  I. — Discharge  from  right  eye  in  a  ease  of  purulent  con- 
junctivitis ;    gonococci   numerous  in    cells   (Stephenson). 

Fig,  II. — Bacillus  of  ^A'^eeks  in  pure  culture  (from  a  photo- 
graph) (Weeks). 

Fig.  III. — Conjunctival  secretion  from  acute  contagious 
conjunctivitis;  polynuclear  leukocytes  with  the  bacillus  of 
"Weeks;  P,  phagocyte  containing  bacillus  of  Weeks;  immers. 
i\.,  oc.  lii   (Morax). 

Fig.  IV. — Secretion  from  a  ease  of  conjunctivitis,  showing 
pneumoeocci  ;   immers.   j'j,  oe.   iii    (Morax). 


GOXORRIir.AL   COXJUXCTIVITIS  OF  ADULTS  105 

»f  this  membrane,  which  may  quickly  be  perforated; 
)roIapse  of  the  iris  with  all  its  evil  consequences 
nay  occur.  Loss  of  the  eye  from  the  formation 
)f  staphyloma,  or  sloughing  of  the  entire  cornea 
ind  phthisis  bulbi,  is  always  iminent.  The  prog- 
losis  is  grave,  and  fully  developed  gonorrheal 
)phthalmia  almost  always  eventuates  in  corneal 
ilceration. 

The  follo\.  ing  method  of  treatment  the  author 
las  found  efficacious  in  a  very  large  experience  in 
:he  wards  of  the  Philadelphia  General  Hospital: 
i)  The  constant  application  of  iced  compresses, 
vhich  in  the  earlier  stages  should  be  continuous, 
Dut  as  the  inflammatory  process  subsides  may  be 
employed  for  periods  of  twenty  minutes  to  half  an 
lour  every  three  or  four  hours.  (2)  The  conjunc- 
:ival  sac  should  be  irrigated  with  sufficient  fre- 
ijuency  to  wash  away  the  rapidly  accumulating 
3US,  using  either  the  bichloride  of  mercury,  i  to 
^000,  or  cyanide  of  mercury,  i  to  5000,  or  a  satu- 
-ated  solution  of  boric  acid.  (3)  Into  the  conjunc- 
tival sac  a  25  per  cent,  solution  of  argyrol  should 
36  instilled  with  sufficient  frequency  to  keep  the 
nflamed  mucous  membrane  immersed  in  the  fluid. 
The  argyrol  has  absolutely  no  germicidal  effect, 
but  it  is  detergent,  sinks  to  the  bottom  of  the 
:ul-de-sac,  and  floats  to  the  surface  pus  and  mucus, 
kvhich  can  thus  be  readily  removed.  In  place  of 
irgyrol,  protargol  is  advised,  in  10  per  cent,  solu- 


106  MILITARY   OPHTHALMIC  SURGERY 

tion,  by  many  surgeons,  but  in  the  experience  of 
the  author  neither  the  argyrol  nor  the  protargol  is 
usually  sufficient,  and  certainly  in  addition  to  the 
argyrol  once  a  day  the  lid  should  be  everted  and 
painted  with  a  2  per  cent,  solution  of  nitrate  of 
silver,  the  excess  to  be  neutralized  with  physiological 
salt  solution  until  the  white  film  which  accumulates 
after  the  silver  application  has  been  thoroughly 
washed  away.  The  lids  are  then  returned  into  place 
and  anointed  with  vaselin,  some  of  which  is  per- 
mitted to  enter  the  sac.  The  cornea  must  be 
watched  with  great  care  for  signs  of  haziness  or 
ulceration,  and  practically  always  it  is  necessary 
to  keep  the  iris  under  the  influence  of  a  mydriatic, 
for  example,  a  drop  of  a  i  per  cent,  solution  of 
sulphate  of  atropin,  two  or  three  times  a  day.  If 
there  is  great  chemosis  of  the  bulbar  conjunctiva, 
and  therefore  great  danger  of  corneal  sloughing, 
incisions  of  this  hard  rim  relieve  the  pressure. 
Occasionally  in  stubborn  cases  Kalt's  method  of 
using  copiously,  a  pint  at  a  time  in  continuous 
irrigation,  a  solution  of  permanganate  of  potas- 
sium, I  to  2000  to  5000,  once  a  day,  acts  most 
favorably.  Naturally,  the  vigor  of  these  applica- 
tions must  be  lessened  as  the  inflammatory  symp- 
toms subside. 

The  spread  of  a  corneal  ulcer  may  sometimes  be 
checked  by  touching  it  with  trichloracetic  acid, 
or  liquid  carbolic  acid,  care  being  taken  to  touch 


COXORRHEAL  CONJUNCTIVITIS  OF   ADULTS  107 

only  the  sloughing  area.  If  one  eye  alone  is  affected, 
the  other  eye  should  be  carefully  protected  by  cov- 
ering it  with  a  Buller's  shield,  made  from  a  watch 
crystal  carefully  put  in  place  with  strips  of  plaster 
or  gauze  and  collodion  (Fig.  i6).    Much  of  the  suc- 


FiG.    i6. — Application  of  Buller's  shield,      (de  Schweinitz.) 


cess  of  the  treatment  of  this  disease  consists  in 
constant  attention,  and  a  special  nurse  or  a  skilled 
orderly  should  be  detailed  for  this  purpose.  Great 
care  must  be  taken  to  destroy  all  cotton,  cloths, 
etc.,  which  come  in  contact  with  the  inflamed  eye. 
The  patient  should  be  isolated,  and  have  his  own 
set  of  treatment  bottles,  etc. 


108  MILITARY   OPHTHALMIC  SURGERY 

DIPLOBACILLUS    CONJUNCTIVITIS. 

This  is  a  troublesome  form  of  conjunctivitis, 
usually  subacute  in  character,  but  sometimes  so 
active  that  it  assumes  acute  proportions.  In  the 
subacute  types  there  is  generally  a  moderate  dis- 
charge, an  irritability  of  the  conjunctiva,  and  fre- 
quently a  soreness  of  the  commissural  angles,  so 
that  the  disease  is  sometimes  called  angular  con- 
junctivitis. Many  of  the  types  of  so-called  sub- 
acute conjunctivitis,  and  even  chronic  conjuncti- 
vitis, are  of  this  character.  The  diplobacillus  of 
Morax  and  Axenfeld  is  most  readily  detected  by 
smears,  examined  under  the  microscope  stained  for 
the  bacteriological  content.  In  these  cases  the 
ordinary  collyria  are  of  little  value,  and  nitrate  of 
silver  is  not  of  much  use;  in  fact,  of  practically  no 
use.  The  specific  is  zinc,  and  the  lids  should  be 
everted  once  a  day  and  touched  with  a  i  per  cent, 
solution  of  sulphate  of  zinc,  the  excess  being  flushed 
off  with  boric  acid,  and  the  patient  given  a  collyrium 
of  sulphate  of  zinc,  2  grains  to  the  ounce,  to  be 
used  frequently.  This  is  practically  a  specific. 
Other  preparations  of  zinc  are  equally  valuable, 
especially  the  sozoiodolate  (i  or  2  per  cent.). 


GAS  CONJUNCTIVITIS  109 

OCULAR  PHENOMENA  OF  "GASSING"  (GAS  CONJUNCTIVITIS). 

In  the  earlier  periods  of  the  war,  drift-  or  cloud- 
gas  attacks  were  delivered  from  compressed  cylin- 
ders and  carried  over  by  means  of  pii)es,  the  gas 
being  composed  of  chlorin  mixed  with  phosgene. 
This  type  of  gas  caused,  in  addition  to  great  irrita- 
tion of  the  respiratory  tract,  a  smarting  and  prick- 
ing sensation  of  the  eyes,  followed  by  blepharo- 
spasm, photophobia,  intense  chemosis  of  the  con- 
junctiva and  well-defined  and  often  violent  conjunc- 
ti\"itis.  In  the  majority  of  instances  severe  corneal 
lesions  did  not  arise,  but  if  the  cornea  was  examined 
carefully  by  means  of  a  loupe,  small  infiltrations 
were  noted,  especially  in  the  periphery,  and  a  kera- 
titis characterized  by  vesicle  formation  has  been 
obser\-ed,  as  has  been  described  by  Major  George 
Derby  and  other  surgeons.  It  is  probable  tha^ 
the  corneal  changes  were  more  frequent  than  the 
records  seem  to  show  and  were  not  detected,  owing 
to  insufficiency  of  investigation.  Occasionally  eyes 
were  lost  as  the  result  of  severe  and  purulent  types 
of  keratitis,  but  this  was  a  very  rare  complication. 

At  the  present  time  drift-gas  attacks  have  been 
abandoned  and  their  place  taken  by  shell  gas,  the 
projectile  being  filled  with  liquid  which  is  converted 
into  gas  by  the  explosion  of  the  shell.  Systematic 
writers  have  classified  shell  gas  according  to  the 
effects  into  lachrymal  or  tear  gas,  of  which  benzyl 
bromide  is  the  type;    eye  and   lung  irritants,   for 


J 


no  MILITARY  OPHTHALMIC  SURGERY 

example,  chlorin ;  lung  irritants  and  asphyxiants,  for 
instance,  phosgene;  eye  and  skin  irritants  charac- 
teristic of  mustard  gas. 

Lachrymal  gas  produces  excessive  epiphora,  pho- 
tophobia and  palpebral  spasm.  Its  ocular  effects 
are  evanescent  and  serious  results  from  the  oph- 
thalmic stand-point  are  rare.  Although  it  has  been 
stated  that  phosgene  has  little  effect  on  the  eyes, 
it  has  -  also  been  noticed  that  this  agent  may  be 
responsible  for  a  mucopurulent  conjunctivitis,  and 
sometimes  phosgene  and  mustard  gas  appear  to 
have  been  combined. 

Mustard  gas  produces  extensive  burns  of  the 
skin,  particularly  along  the  inner  sides  of  the  thighs, 
on  the  genitalia  and  where  the  skin  is  thin  and 
moist.  A  large  percentage  of  soldiers  subjected  to 
mustard-gas  attacks  present  ocular  lesions.  The 
lids  are  swollen  and  may  be  covered  with  blisters 
or  bullae;  photophobia  and  lacrimation  are  intense 
and  the  conjunctival  lesions  vary  from  moderate 
hyperemia  to  pronounced  injection,  extensive  white 
chemosis  and  edema,  the  affected  conjunctiva 
somewhat  resembling  a  mucous  membrane  which 
has  been  brushed  with  a  strong  solution  of  nitrate 
of  silver.  In  the  majority  of  these  cases  there  is 
corneal  involvement,  roughening  of  the  epithelium 
and  sometimes  well-marked  band-like  opacity  of 
the  cornea.  Occasionally  there  are  severe  ulcers 
and  even  hypopyon-keratitis,  but  these  dire  results 


GAS  CONJUNCTIVITIS  111 

are  comparatively  rare.  Occasionally  temporary 
loss  of  vision  has  been  noted.  Whether  this  is  due 
to  the  violence  of  the  local  reaction  or  to  intra- 
ocular changes  has  not  been  satisfactorily  deter- 
mined. Some  French  observers  have  described  a 
form  of  retinitis. 

Many  of  the  soldiers  with  mustard-gas  conjunc- 
tivitis arc  able  to  return  to  their  Units  at  the 
expiration  of  three  or  four  weeks,  ultimate  recovery 
being  the  rule.  Occasionally,  however,  the  con- 
valescence is  much  prolonged ;  a  few  eyes  have 
been  totally  lost.  To  give  some  idea  of  the  fre- 
quency of  the  corneal  complications,  it  may  be 
stated  that  in  an  analysis  made  by  Teulieres  of 
1500  men  who  had  been  gassed,  there  were  only 
23  with  severe  eye  lesions,  3  corneal  ulcers  and 
I  panophthalmitis.  Sometimes  nebulous  cornea? 
result.  Occasionally  the  leukomas  are  marginal, 
the  central  vision  not  being  disturbed. 

The  most  satisfactory  treatment  consists  in  a 
lotion  of  a  I  per  cent,  solution  of  sodium  bicar- 
bonate. Liquid  albolene  or  paraffin  is  employed 
with  benefit,  especially  if  later  irrigation  with  an 
ordinary  saline  solution  is  used.  Apparently  an 
ordinary  oil,  for  example,  castor  oil,  does  not  act 
as  satisfactorily  as  the  albolene  or  paraffin.  Dionin 
has  been  recommended  for  the  corneal  complica- 
tions, but  there  is  much  difference  of  opinion  with 
reference  to  its  efficiency.     As  the  pupils  are  apt 


J 


112  MILITARY   OPHTHALMIC  SURGERY 

to  be  contracted  and  ciliary  irritation  is  frequent, 
atropin  is  advisable.  The  eyes  should  be  protected 
during  the  earlier  stages  with  a  shade  or  dark 
glasses,  but  the  patients  should  be  encouraged  to 
to  be  up  and  about  as  soon  as  possible  lest  they 
pass  into  a  stage  characterized  by  photophobia  and 
asthenopia,  when  really  there  are  no  local  ocular 
lesions  remaining  to  account  for  them. 


EXAMINATION  OF  MALINGERERS. 
By  Walter  R.  Parker,  M.D., 

COLONEL,  M.  C,  U.  S.  A. 


Malingerers  who  wish  to  evade  military  service 
through  feigning  faulty  visual  acuity  may  be 
divided  into  three  classes  as  follows: 

"A" — Those  who  claim  total  loss  of  vision  in 
one  eye. 

"B" — Those  who  claim  partial  loss  of  vision  in 
one  or  both  eyes. 

"C" — Those  who  claim  total  blindness  in  both 
eyes. 

Representatixes  of  any  group  may  ha\e  a  normal 
acuity  of  \ision  or  may  exaggerate  a  defect  actually 
pre:^cnt. 

The  visual  rcciuirement  for  recruits  l)cing 
for  unlimited  military  service  20/100  in  each  eye 
correctable  to  20/40  in  one  eye  and  for  limited 
military  service  20/200  in  each  eye  correctable  to 
20  '40  in  one  eye,  it  is  only  necessary  to  prove  that 
at  least  this  amount  is  present,  leaving  the  deter- 
8  (113) 


114  MILITARY   OPHTHALMIC  SURGERY 

mination  of  the  actual  acuity  of  vision  for  future 
examinations. 

In  testing  for  malingering  the  medical  examiner 
should  bear  in  mind  that  detection  is  more  likely 
to  result  when  the  man  is  allowed  to  believe  that 
his  case  is  regarded  from  the  first  as  genuine  and 
that  his  story  is  not  discredited.  There  is  something 
indefinable  in  the  bearing  of  the  malingerer  w4iich 
experience  alone  can  detect.  He  may  be  self- 
assertive  and  overconfident;  he  may  be  hesitating 
and  evasive.  Careful  observation  should  be  made 
of  his  conduct  and  every  movement  noted.  The 
nature  of  the  man's  answer  should  be  taken  into 
account  and  considered  in  the  light  of  the  kind  of 
reply  that  is  given  when  a  genuine  refraction  case 
is  being  dealt  with. 

Equipment. 

1.  Trial  frame,  i  blank,  i  green  glass,  i  red 
glass.  Spherical  lens,  +i6,  -f-6,  +3,  +0.25,  —3, 
-2,   -I,  -0.25. 

2.  Two  lO-degree  prisms. 

3.  Ophthalmoscope.      Electric. 

4.  Condensing  lens. 

5.  One  loupe. 

6.  Snellen's  malingering  test  glass  (FRIEND) 
in  red  and  green  letters  on  glass. 

7.  Special  test  card.  Instead  of  the  single  top 
letter  representing  20/200,  the  scale  should  be 
rearranged  so  that  it    begins  with  the   top  letter 


EXAMINATION   OF   MALINGERF-RS  115 

20/100  followed  by  two  20/70,  three  20/50,  etc.,  in 
imitation  of  the  standard  types.  Thus  the  man 
who  has  been  coached  to  read  but  four  lines  and 
reads  them  has  passed  the  standard  without  being 
aware  that  he  has  committed  himself. 

8.  Test  card,  with  letters  reversed  for  use  in 
mirror. 

9.  Test  cards,  one  line  of  type  on  each  card  and 
three  cards  for  each  size  of  letters.  These  cards 
are  to  be  exposed  to  view  at  a  distance  of  twenty 
feet,  one  card  at  a  time.  Thus  the  recruits  do  not 
know  to  which  line  the  letter  corresponds  on  the 
regular  test  card. 

10.  One  stereoscope  and  cards. 

1 1 .  Retinoscope,  electric  and  reflecting  mirror. 

12.  Drugs. 

Euphthalmin  hydrochlorate  (disks  if  pos- 
sible;. 
Homatropin  (disks  if  possible). 
Cocain  hydrochlorate  (tabloid  if  possible). 
Eserine  salicylate   (disks  if  possible). 
Methods   of    Examination. — CLASS   "yl." — 
(Total  loss  of  vision  in  one  eye.) 

(a)  A  prism,  base  downward,  is  placed  before 
the  admittedly  sound  eye  while  the  man  looks  at 
a  distant  point  of  light  or  candle  flame.  If  he  sees 
two  lights,  binocular  xision  is  proved.  The  examiner 
may  \ary  the  test  by  placing  the  prism  before  the 
"blind"  eye,  either  base  up  or  base  down. 


^ 


116  MILITARY   OPHTHALMIC   SURGERY 

(b)  A  prism  of  lo  degrees  with  base  outward  is 
placed  before  the  ''bHnd"  eye.  If  there  is  any 
sight  in  this  eye,  double  vision  will  be  produced 
and  the  eye  will  be  seen  to  move  inward  to  correct 
it  and  fuse  the  two  images. 

(c)  The  "blind"  eye  is  covered.  A  prism  of  lo 
degrees  with  the  apex  up  is  placed  before  the 
sound  eye  in  such  a  position  that  its  edge  lies  hori- 
zontally across  the  center  of  the  pupil.  This  pro- 
duces monocular  diplopia.  The  prism  is  then  moved 
upward  so  as  to  be  completely  in  front  of  the 
sound  eye,  and  at  the  same  time  the  "blind"  eye 
uncovered.  If  diplopia  is  produced  or  admitted, 
there  is  sight  in  the  "blind"  eye. 

(d)  Test  with  Colored  Glasses  and  Letters. — This 
consists  in  directing  the  individual  to  read  a  row  of 
red  and  green  letters  through  a  red  and  green  glass. 
The  red  letters  will  be  invisible  to  the  eye  that  has 
the  green  glass  before  it  and  vice  versa,  but  if  all 
the  letters  are  correctly  read  irrespective  of  their 
color,  there  must  be  sight  in  the  "blind"  eye. 
Further,  the  smallest  letters  correspond  with  the 
20/40  test  letters  and  if  read  at  twenty  feet  indicate 
vision  up  to  standard.  To  determine  this,  reverse 
the  glasses  and  direct  the  letters  to  be  read.  As 
these  letters  are  seen  by  transmitted  light,  the 
proper  illumination  back  of  the  chart  must  be 
observed. 


EXAMINATION    OF   MALINGERERS  117 

(e)  Tests  ivith  Trial  Glasses. — A  high  phis  glass 
is  placed  before  the  sound  eye  and  a  low  plus  or 
minus  before  the  "blind"  eye.  If  the  distant  type 
is  read,  the  vision  in  the  "blind"  eye  is  good.  Or 
a  plus  6  diopter  lens  is  placed  before  the  sound  eye 
and  the  test  type  placed  very  close  to  the  eyes  and 
the  patient  allowed  to  read.  Gradually  increase 
the  distance  until  the  card  is  beyond  the  focus  of  the 
sound  eye.  If  the  patient  continues  to  read,  he  is 
seeing  with  the  alleged  "blind"  eye, 

if)  The  Stereoscopic  Test. — This  may  be  made 
with  the  ordinary  stereoscope,  the  printed  matter 
so  arranged  that  certain  portions  of  it  are  not 
present  before  one  or  the  other  eye.  If  the  patient 
reads  consecutively,  he  is  reading  with  both  eyes. 
This  test  may  be  greatly  varied  by  using  different 
symbols  or  figures,  only  a  portion  of  which  is 
present  on  each  side  so  that  it  requires  binocular 
vision  to  see  the  complete  figure. 

{g)  The  action  of  the  pupil  must  be  carefully 
tested,  there  usually  being  no  movement  to  light 
stimulation  when  the  eye  is  blind. 

If  the  examiner  is  not  satisfied  the  following 
examinations  should  be  made: 

Oblique  Examination. — A  careful  examination  of 
the  cornea  should  be  made  with  the  aid  of  a  con- 
densing lens  and  a  loupe. 

Ophthalmoscopic  E.xamination. — A  searching  ex- 
amination with  the  ophthalmoscope  should  be  made 


118  MILITARY   OPHTHALMIC  SURGERY 

together  with  an  estimation  of  the  refractive  error. 
The  pupil  should  be  dilated  if  necessary. 

CLASS  "5."— Partial  loss  of  vision  in  one  or 
both  eyes. 

The  most  common  manifestation  of  malingering 
takes  the  form  of  a  statement  that  one  eye  is 
imperfect,  and  men  pleading  this  disability  may  be 
divided  into  two  classes: 

(a)  Those  who  pretend  to  have  an  optical  defect. 

(b)  Those  who  know  they  have  an  optical  defect 
and  exaggerate  its  effect. 

No  hard-and-fast  tests  can  be  prescribed  for  the 
detection  of  these  cases.  Much  depends  on  the 
alertness  and  ingenuity  of  the  medical  examiner. 

The  tests  with  prisms  are  not  applicable  here, 
for  there  is  not  pretended  blindness  in  one  eye, 
but  simply  an  alleged  diminution  of  the  visual 
acuity. 

Methods  of  Examination. — CLASS  "B." 

(a)  Special  test  card.     (See  equipment  No.  7.) 

(b)  Single  line  test  cards.  (See  equipment 
No.  8.) 

(c)  Trial  frame  test.  Place  a  trial  frame  upon 
the  man's  face  and  put  before  the  sound  eye  a  high 
convex  lens  (-|-i6D),  and  before  the  blind  eye  a 
plain  or  weak  lens  (0.25)  which  will  not  interfere 
with  vision.  If  letters  placed  at  distance  of  twenty 
feet  are  read,  the  fraud  is  at  once  exposed. 


EXAMINATION  OF  MALINGERERS  119 

(d)  Mirror  Tests  with  Special  Test  Cards.  (See 
cquii:)ment  No.  7.) — Test  cards  are  used  which  are 
identical,  except  one  has  the  letters  reversed.  The 
recruit  is  directed  to  read  the  letters  on  the  chart 
across  the  room,  and  then  in  a  mirror  beside  it, 
which  reflects  letters  that  are  placed  over  his  head. 
The  letters  seen  in  the  mirror  are  located  double 
the  distance  of  the  direct  letters  from  the  man 
being  examined.  The  malingerer  is  apt  to  read  in 
the  mirror  the  line  which  he  read  on  the  first  card, 
showing  that  his  vision  is  twice  as  good  as  he 
pretends. 

(e)  Obliciue  examination  with  condensing  lens 
and  loupe. 

(/)  Ophthalmoscopic  Examination. — It  is  prob- 
able that  the  malingerer  will  resist  the  ophthalmo- 
scopic examination  by  frequent  winking  or  rolling 
of  the  eyes.  In  this  event,  it  is  best  to  caution  the 
man  that  a  report  of  his  vision  must  be  made,  and 
then  to  postpone  further  examination  until  after 
the  next  few  recruits  have  been  examined. 

Estimate  the  refractive  error  with  the  use  of  the 
ophthalmoscope.  If  no  error  of  marked  degree 
exists  and  the  media  and  fundi  are  normal,  the  rela- 
tion between  the  alleged  vision  and  the  refractive 
condition  furnishes  an  important  clue.  If  the 
error  is  about  +4.00  or  —2.00  the  visual  acuity 
could  l)c  about  20/100,  but  when  the  defect  cannot 
be    accounted    for   objectively    and    the    vision    is 


120  MILITARY  OPHTHALMIC  SURGERY 

brought  from  20/100  to  20/50  or  20/30  by  means  of 
a  low  plus  or  minus  glass,  the  man  is  malingering. 

(g)   Retinoscopy. 

CLASS  "  C". — Total  Blindness  in  both  Eyes. 
— Total  blindness  in  both  eyes  is  rarely  claimed. 
It  is  almost  impossible  for  a  man  to  deceive  those 
who  see  him  daily,  and  there  will  usually  be  found 
some  acquaintance  who  is  ready  to  testify  against 
him. 

Every  case  of  total  blindness,  the  cause  of  which 
cannot  be  determined,  should  be  regarded  with 
suspicion. 

If  an  applicant  is  actually  blind  in  both  eyes  and 
there  exists  no  adhesion  of  the  iris,  the  pupils  are  as 
a  rule  well  dilated  and  react  slightly,  if  at  all,  to 
light  stimulation. 

A  test  pretending  to  discover  the  applicant's 
ability  to  determine  direction  may  be  made  in  the 
hope  of  catching  him  off  his  guard.  The  examiner 
may  go  to  one  side  of  the  room  and  ask  the  patient 
to  approach  him.  In  his  way  may  be  placed  some 
articles  of  furniture,  though  care  must  be  taken 
that  the  patient  may  not  injure  himself.  Observa- 
tion should  be  made  as  to  whether  or  not  the 
patient  avoids  the  objects  so  placed. 

A  patient  who  complains  of  sudden  total  loss  of 
vision  must  assume  the  attitude  and  gait  of  a  blind 
man,  walking  stiffly  and  hesitatingly,  with  hands 


KXAMIXATION  OF    MALINGERERS  121 

outstretched,  face  imjiassu'e,  expression  dull;  eyes 
turned  ui)ward,  eyelids  immovable  even  when 
flaslu's  of  lii;ht  or  objects  are  quickly  brought 
toward  his  eyes.  The  occlusion  bandage  may  be 
applied  for  a  day  to  ascertain  if  the  patient  can 
maintain  the  role  of  the  blind  patient  as  well  as 
when  both  eyes  are  uncovered. 

Schmidt-Rimpler  suggests  that  the  patient  be 
told  to  look  at  his  own  hand,  which  he  holds  a  short 
distance  from  his  eyes.  A  blind  man  will  easily 
succeed  in  casting  his  eyes  In  the  direction  of  his 
own  hand  while  a  pretender  may  afTect  to  look  in 
a  different  direction,  believing  that  he  is  thereby 
deceiving  the  examiner.  The  examiner  may  use 
the  prism  test  described  on  p.  Ii6  (b). 

Occupation. — The  man's  occupation  in  ci\il  life 
may  ha\e  been  such  that  it  could  not  have  been 
followed  without  more  vision  than  he  claims. 

In  the  absence  of  ocular  defects,  continuous  and 
persistent  blepharospasm,  the  use  of  colored  glasses, 
eye  shades  or  e>-e  l)andages  should  be  regarded 
with  suspicion. 

Diplopia, — Cases  of  malingering  arc  occasion- 
ally met  with  in  which  the  man  complains  that 
he  sees  double.  These  must  be  investigated  with 
the  application  of  the  ordinary  tests  as  if  they 
were  genuine,  with  every  precaution  taken  to  guard 
against  a  serious  ners'ous  lesion  being  o\'erlooked. 


: ^ 


IL'2  MILITARY  OPHTHALMIC  SURGERY 

CojNUNCTiviTis. — Inflammation  of  the  lids  is 
sometimes  produced  by  introducing  irritating  sub- 
stances in  the  conjunctival  sac,  ipecacuanha 
powder,  soap,  particles  of  sand  or  other  foreign 
matter  being  used  for  such  purposes. 

The  characteristics  of  this  form  of  conjunctivitis 
are  its  sudden  onset,  usually  in  one  eye  alone,  the 
marked  irritation  and  swelling  of  the  lower  conjunc- 
tival sac,  with  a  moderate  amount  of  secretion. 
Sometimes  the  lids  have  an  erysipelatous  appear- 
ance, and  great  difficulty  is  experienced  in  opening 
them.     Corneal  ulcers  have  been  observed. 


DISEASES  OF  EYE  AND  ADNEXA.^ 


Abscess  of  lid 

Amaurosis 

Amblyopia 

exanopsia 

hysterical 

nocturnal 

toxic 
Ankyloblepharon 
Aphakia 
Astigmatism 
Blepharitis 
Blepharospasm 
Cataract 
Cellulitis  of  lids 
Chalazion 
Choked  disk 
Choroidal  tumor 
Choroiditis 

suppurating  choroiditis 
Color-blindness 
Conical  cornea 
Conjuncti%-itis 

acute  catarrhal 

chemical 

chronic 

follicular 

granular  (trachoma) 

phlyctenular 

purulent 

traumatic 

vernal 
Cyclitis 


Dacryoadenitis 
Dacryocystitis 
Detachment  of  choroid 

of  retina 
Ectropion 
Entropion 
Epiphora 
Exophthalmos 
Fistula  of  lacrimal  sac 
Glaucoma 

acute 

chronic 

secondary 
Hemianopsia 
Hemorrhage  into  retina 

subconjvnictival 

into  vitreous 
Herpes  zoster  ophthalmicus 
Hordeolum 

Hyperemia  of  conjunctiva 
Hyphemia 
Hypopyon 
Iridocyclitis 
Iritis 

acute 

chronic 

syphilitic 
Keratitis 

herpetic 

non-ulcerative 

parenchymatous 

phlyctenular 


'  Lists  furnished  for  the  Surgeon-General's  GfTice  by  the  Section  of 
Ophthalmology. 


(123) 


124 


MILITARY  OPHTHALMIC  SURGERY 


Keratoiritis 

Keratomalacia 

Leukoma 

adherens 
Lacrimal  obstruction 
Lagophthalmos 
M  yopia 

Neuritis  (optic) 
Neuroretinitis 

albuminurica 
Nystagmus 

Obstrtiction  of  retinal  arteries 
Opacity  of  vitreous 
Ophthalmoplegia 

externa 

interna 
Orbital  cellulitis 
Panophthalmitis 
Paralysis  of  ocular  muscle 
Presbyopia 


Proptosis 

Pterygium 

Ptosis 

Retinitis 

albuminurica 

diabetic 

hemorrhagic 

syphilitic 
Retrobulbar  neuritis 
Scleritis 
Snow-blindness 
Staphyloma  of  cornea 
Symblepharon 
Sympathetic  ophthalmitis 
Synechia 

Thrombosis  of  retinal  veins 
Ulcer  of  cornea 
Uveitis 
Xerosis 


EYE  INJURIES. 


Burns  of  conjunctiva 
Concussion  of  eye 
Contusion  of  eye 
Ecchvmoses  of  conjunctiva 

of  lids 
Foreign  bodies  in 

anterior  chamber 

choroid 

conjunctiva 

cornea 

iris 

lens 

lids 

orbit 

sclera 

vitreous 
Injury  to  optic  nerve 
Iridodialysis 
Penetrating  wounds  of 

ciliary  body 


Penetrating  wounds  of 

cornea 

lens 

lids 

orbit 

sclera 
Perforating  wounds  of 

cornea 

globe 

orbit 
Prolapse  of  ciliary  body 

of  iris 
Ruptures  of  choroid  and  retina 

of  cornea 

of  globe 
Tears  of  lids 

multiple 

simple 
Traumatic  cataract 


EYE  OPERATIONS. 


Advancement  of  eye  muscle 
Blepharoplasty 
Canthoplasty 
Canthotomy 
Cataract  extraction 
Chalazion  operation 
Conjunctival  keratoplasty 
Dilation  of  lacrimal  duct 
Discision  for  cataract 
Ectropion  operation 
Entropion  operation 
Enucleation,  simple 

with  implantation 
Epilation 
Evisceration 
Excision  of  tarsus 
Exenteration 

Extirpation  of  lacrimal  sac 
Foreign  bodies,  removal  from 

anterior  chamber 

conjunctiva 

cornea 

lens 

lids 

magnet,  extraction  of 


Foreign  bodies,  removal  from 

orbit 

sclera 

vitreous 
Incision  of  abscess 

of  lacrimal  sac 
Iridectomy 
Iridotomy 

Kronlein's  operation 
Paracentesis  of  cornea 
Plastic  on  lids 
Probing  of  lacrimal  duct 
Pterygium 
Ptosis  operation 
Saemisch  operation 
Sclerocorncal  trephining 
Sclerotomy 

Staphyloma  operation 
Suction  for  traumatic  cataract 
S\Tnblepharon  operation 
Tarsorrhaphy 
Tenotomy  of  eye  muscle 
Trachoma,  expression  for 
Trichiasis  operation 


(125) 


INDEX. 


A 

Amblyopia,  hysterical 51 

nocturnal 51 

Anatomy  of  eyelids ;      ....  66  to  69 

Army  lists  of  eye  diseases  and  operations 123 

B 

Burns  of  lids 12 

treatment  of 14 

C 

C.\TARACT,  traumatic 37  to  40 

treatment  of 39  to  40 

Choked  disk 49 

Ciliary  body  prolapse 36 

Commotio  retinae 10 

Concussion  of  eyeball 37 

treatment  of 38 

Conjunctival  keratoplasty 31 

description  of 32  to  37 

Conjunctivitis 103 

acute  simple  (catarrhal) 103 

treatment  of 104 

chronic  (diplobacillus) 108 

treatment  of 108 

follicular 81 

gas 109 

gonorrheal 104 

treatment  of 105  to  107 

Parinaud's 80 

tubercular 80 

vernal 80 

(127) 


INDEX 


Contusion  of  eyeball  . 
treatment  of 
hypotony 
Corneal  abrasions 

treatment  of 


ulcers 


treatment  of 


43 


Cranial  injuries 48 


D 


DiSTICHIASIS 


43  to  44 
to  51 


75 


E 

Ectropion 75 

Entropion 75 

Enucleation 16  to  18 

indication  for 5p 

with  implantations 16 

Evisceration 20  to  21 

indication  for 60 

Eye,  penetrating  wounds  of 15 

Eyelids,  wounds  of 45 

F 

Fluorescein  solution 15 

Foreign  bodies  in  anterior  chamber 15  to  27 

in  cornea      .....  12 

treatment  of 12  to  13 

in  globe 22 

treatment  of          22  to  23 

in  iris 14.  27 

treatment  of          14.  27 

in  lens 27 

magnetic 22  to  29 

non-magnetic 29 

in  orbit         41 

in  vitreous 22  to  29 

G 

Gas  bacillus  in  orbit 41 

conjunctivitis 109 

Glaucoma  (secondary) 37 


INDEX  129 

H 

Hemianopsias 50 

Hemorrhage,  orbit 40 

retina 48 

vitreous 10 

Hyphemia 10 

Hypotony,  contusion 11 

I 

Increased  intracranial  pressure 49 

Instruments 55  to  57 

IridocycHtis 31.  36 

Iridodialysis 10 

Iris  (prolapse  of)         32,  36 

Irrigation 33,  39 

K 

Ker.-\titis  (neuroparalytic) 42 

L 

Lagophthalmos         42 

Lens,  dislocation  of          10,  38 

in  vitreous 3*^ 

Lid  wounds 12,  45  to  46 

M 

Magnets 23  to  27 

Malingerers 113 

blindness  feigned  by 120 

classes  of 113 

colored  glasses  and  letters  for 116 

conjunctivitis  in 121 

diplopia  in 121 

equipment  for  examination 114 

examinations  of 113 

methods  of  examination  for 115  to  121 

mirror  tests 119 

occupation  tests 121 

ophthalmoscope  tests 119 

prism  tests 119 

stereoscope  test         115 

trial  glasses  test 115 

Meningitis 49-50 


J 


N 

NosopHEN  ointment 14 

O 

Optic  neuritis 49,  50 

Orbit,  injudicious  exploration  of 44 

penetrating  wounds  of 40 

perforating  wounds  of 40 

Orbital  cellulitis  20,  21,  41 

P 

Pannus 74 

treatment  of 99,  100 

Panophthalmitis 20 

Paralyses  of  ocular  molar  nerves 50 

Penetrating  wounds  of  eye 15  to  37 

of  orbit 40 

Perforating  wounds  of  eye           15  to  37 

of  orbit          40 

Prophylaxis  (against  eye  injuries) 46,  47 

Proptosis 42 

Prosthesis,  cartilage 18 

glass 16 

metallic 16 

Psychoneuroses 51 

R 

Refraction 51 

Retinal  edema 48 

separation 30 

Retinitis  pigmentosa 51 

Rupture  of  choroid 10 

of  globe 10,  II 

of  retina 10 

S 

Scotomas 50 

Suction 39 

Sympathetic  ophthalmitis 36 


131 


T 

Trachoma 6i 

acute 74 

brossaRe  in 87 

causes  of 76  to  78 

chemical  treatment  of 76 

chronic 71 

cicatricial .  72 

curettage  for 93 

definition  of 69 

diagnosis  of 79 

distribution  of 62  to  66 

excision  for 93 

combined 94  to  99 

follicular 72 

grattage  in 87 

papillary 71 

pathology  of 78 

predispositions  to 65 

prognosis  of 100,  loi 

prophylaxis 102 

symptoms  and  course  of 72  to  76 

treatment  of 83 

mechanical 86  to  92 

Trench  nephritis 42 

Trichiasis 75 

W 

White's  ointment 14 

X 

X-RAY  localization 23,  41 


\^6wmi 

? 

3 

4 

5 

6 

ALL  BOOKS  MAY  BE  RECALLED  Al 
RENEWALS  MAY  BE  REQUESTED 


DUE  AS  STAMPED  BEL( 

FORM  NO.  DD  23,  2.5nn, 


UNIVERSITY  OF  CAI 
12780  BERKELE 


